Fletcher Brady, Janet M.S.
Disease risk management is no longer a new concept that only a few forward-thinking managed care organizations have developed into everyday programs. Disease management, otherwise known as "the effective management of chronic disease, including the prevention of chronic disease in a given population utilizing evidence-based programs, services, and resources to improve an individual or populations' overall health, fitness, and quality of life," is crucial to the future success of health care. The economics of health care in the United States is driving the emergent need for well-designed evidence-based disease management programs. Recent studies show that over 125,000,000 individuals in the United States are living with one or more chronic health conditions. The estimated direct and indirect costs of diabetes alone have risen to $174 billion a year, whereas arthritis and heart disease, including strokes, cost $128 billion a year and $448 billion, respectively (1).
The profile of diseases contributing the most to illness, disability, and death in the United States has drastically changed over the last century. Heart disease, stroke, cancer, and diabetes are the most common and preventable of all health challenges and in the United States; 7 out of every 10 deaths result from a potentially preventable chronic disease (2).
Such preventable expenses add to the escalating costs of health care. Table 1 shows the percentage of gross domestic product that national health expenses have historically averaged and the projection for escalation by the year 2016. To further establish the financial driver behind disease management, observe in Table 2 the decline since 1955 in workers paying into the Social Security Fund compared with the projected available number of workers that will be paying into the fund in 2030. Couple this reality with the fact that "heart disease and stroke are one of the top causes of disability in the United States workforce, and more than 80 million Americans (1 in 3) are living with one or more types of cardiovascular disease" (3). As our population demographics reach the greatest number of retirees in the history of America, it is imperative more than ever for all health care providers to establish a foundation of preventive health care with a focus on disease management. Thus, it is essential that providers need to analyze the chronic disease risk and management needs of those they serve. A holistic approach needs to be developed to combat the ongoing challenges of chronic disease, providing an environment and opportunity for individuals to realistically and more effectively manage their health and chronic disease, while also providing those who are currently free from disease with a realistic ongoing prevention plan and resources to stay healthy. Medical fitness centers are well positioned to expand their integrated models to better serve the chronic disease population.
ANCILLARY SERVICES FOR DISEASE RISK MANAGEMENT IN MEDICAL FITNESS CENTERS TODAY
Results of a phone survey of over 30 medical fitness centers indicate that many centers offer a fairly well-developed line of educational programs and services targeting chronic disease. However, many programs require an enhanced model that will allow services to be more clearly understood and accessed by such an individual. Most centers surveyed reported that they are in the process of reviewing and redesigning their system, if necessary, with an improved seamless program. Centers that were offering programs were usually doing so in a system where they were operating independently from one another-not only in program design and structure, but also in various geographic locations (in the medical fitness center, hospital, medical office building, or elsewhere in the community). For example, many centers had cardiac rehab, diabetes, arthritis, and cancer programs, yet rarely were all of these programs linked in a seamless system of access, management, and programming for participants/patients within the medical fitness center. Communications to participants/patients were not coordinated, and more apparent was the lack of coordinated physician reporting. Realizing the challenges physicians face on a daily basis, coordinating physician communications would not only provide a comprehensive review of how the individual is doing, but also maintain that important physician link and line of communication.
INNOVATIONS IN SEEKING PHYSICIAN REFERRALS AND EFFECTIVE MANAGEMENT OF REFERRALS
Developing a disease management program will set your center apart from other facilities in your area that are not medically integrated. Given the number of individuals in your community that are challenged with chronic disease, establishing a focused program with a single referral point will position your center to be the preferred option when individuals in your community are ready to seek information or take action.
One outstanding option to consider using is the evidence-based "Chronic Disease Self-Management Program (CDSMP)" developed by Kate Lorig, Ph.D., director of the Stanford University School of Medicine Patient Education Research Center. The CDSMP is a workshop-based program that is available through a Chronic Disease Self-Management Training Program through the Stanford School of Medicine Patient Education and Research Center. The CDSMP recommends training one health care professional and one lay individual that are currently challenged with a chronic disease. Once staff are trained, centers may then become licensed to offer the program. In the workshop-based program, people with different chronic health problems attend workshops together with two trained leaders, one or both of whom are non-health professionals with a chronic disease themselves.
Published outcomes on the CDSMP report that individuals who went through the program, when compared with those who did not, demonstrated significant improvements in exercise, cognitive symptom management, communication with physicians, self-reported general health, health distress, fatigue, disability, and social/role activities limitations. They also spent fewer days in the hospital, and there also was a trend toward fewer outpatient visits and hospitalizations.
The National Council on Aging (NCOA) and Stanford University School of Medicine Patient Education Research Center just recently announced that they have developed a partnership to offer an online version of the CDSMP that is due out by the end of 2008. The online version has proven to be very effective in improving health status for people with chronic diseases. The NCOA will host and distribute the program. The NCOA and Stanford will work together on quality assurance, improving usability, and enhancing knowledge about the program's cost-effectiveness. Thanks to the partnership between NCOA and the Stanford University School of Medicine Patient Education Research Center, the online version of the CDSMP offers a more accessible option that centers can link to and offer to individuals through their medical fitness center. For more information on the CDSMP offered by the Stanford University School of Medicine Patient Education Research Center, go to: http://patienteducation.stanford.edu/training (4).
The Roseville Health and Wellness Center, in Roseville, CA, serves as an outstanding example of a medical fitness center that has succeeded in developing a comprehensive program. With a physician and two physical therapists as owners, the center has focused since their beginning 8 years ago, on programming designed around a medically integrated model. Through this model, they developed an innovative approach to embrace the chronic disease population in their area by developing a successful physician enrollment and referral program called the Physician Wellness Network. The Roseville Health and Wellness Center invites physicians to become network members. By becoming a member, physician offices are provided with a personal wellness concierge. The concierge is solely responsible for receiving all referrals from the physician office, personally handling all referrals, and leading each referred individual through a series of steps to establish their personal health and fitness program. If the individual is not yet ready to begin a fitness program, then appropriate needs are addressed such as behavioral or support counseling, nutritional education, or disease-specific education. Special attention is given in the program design process to follow the recommendations from the physician while designing a program that meets the readiness, goals, and preferences of the individual. Monthly updates, if requested, are provided to the referring physician by the personal wellness concierge to maintain physician communication. The center reports that about 50% of the physicians take advantage of the monthly reporting, with the overall perceived response by physician offices to the program rated as "outstanding." All services for this program are included in the center's registration fees. Additional fees are charged if the individual requires ongoing personal training or education beyond their initial intake, program design, and first personal training session. Individuals challenged with chronic disease are often plagued by numerous health and fitness obstacles. Developing a program design similar to the Roseville model provides an individual with an advocate to guide them in the often complicated world of health, fitness, and disease management.
Another successful medical fitness program, Beach Cities Health District in Redondo Beach, Calif, formerly had a position dedicated to marketing their programs and services to local physicians. When budgets were tight, the position was eliminated. Recently, administration decided to again fill the position, and the results of the direct physician medical fitness marketing program have proven successful. Beach Cities Health District Communications and Marketing Director Pamela Corante-Hansen reports that the position is a tremendous asset in not only marketing their services to local physicians, but also provides an effective communication link that would not otherwise be there if the staff simply relied on communications via medical staff meetings and printed communication. Beach Cities Health District staff has gained the confidence of their physicians, allowing greater disease management program development and improved communication between the participant, center staff, and the physician.
LEVERAGING MEDICAL FITNESS AS A CORE COMPONENT OF DISEASE MANAGEMENT
Years of research have overwhelmingly proven the benefit that exercise has on overall health outcomes, yet many medical communities still struggle to understand and embrace these proven benefits. For example, a 2007 article published in Medicine & Science in Sports & Exercise® found that children with asthma who improve their physical fitness are likely to experience beneficial effects on disease control and quality of life. The study not only found that effective aerobic training improved cardiopulmonary fitness, but also decreased daily use of inhaled steroids in asthmatic children (5).
Given the escalating challenge of chronic disease in our society, there is no time like the present to begin evaluating where you can begin to make a difference in your community, one chronic disease at a time. From linking your center with breast cancer survivors in your area and presenting the tremendous benefits that regular exercise has on their overall health, fitness, and survival rate to working with cardiac rehab patients to assess and track their functional fitness, chronic disease management can be started very simply from within one key program. If your center is not ready or staffed to do a comprehensive disease management program, starting with just one program such as cardiac rehab can make a tremendous impact. For example, did you know that the number one cause of death of older adults is complications from slips and falls? Recognizing this statistic and then completing a functional fitness and fall risk assessment to identify individuals at risk for falling in cardiac rehab and then offering a balance development program for at-risk individuals is a first step in the right direction.
EVALUATE YOUR MEMBER MANAGEMENT PROCESS-MOVE BEYOND SWIPING THE MEMBERSHIP CARD
If you are like most medically integrated fitness centers, you have outstanding programs and valiant goals designed to not just improve overall health and wellness, but to also improve quality of life and reduce the direct and indirect health care costs of chronic disease. However, you need to be sure your programming makes sense from a disease management and health improvement perspective. If you are currently providing health education and/or disease-specific prevention and management programs in combination with your fitness programs, consider taking some time to evaluate how your programs are designed and presented to the public, physicians, and other health professionals. If your programs tend to be offered in a more random format, and are not well connected with each other, consider how you can redesign access points, communication, marketing, and resources to provide a more cohesive outcomes-driven program. Review how new members are evaluated when they join and reevaluated as an ongoing member to track overall success in their health and fitness goals. If you don't currently have technology that allows you to effectively record and manage baseline data, establish and monitor goals with members, identify readiness to change, and develop a customized program, consider acquiring a system that will allow you to efficiently gather and manage this vital information. Systems are currently available that allow for an interface with your members, providing them with tools and resources to more effectively manage their health, fitness, and chronic disease risk factors. It is important to also consider your center as an access point for information for your members and your community. Review the Web site for your center and be sure you have a clear listing of all your available programs and services and customized information in regard to your chronic disease management programs, resources, and services.
BECOME A RECOGNIZED RESOURCE IN YOUR COMMUNITY FOR CHRONIC DISEASE
Focus on establishing your medical fitness center as the most informed, innovative, and accessible resource for chronic disease in your area. Your center should be the place your community thinks of, where local physicians refer, and your local and even regional media recommend for information and resources pertaining not just to fitness, but also for information on the effective management and prevention of chronic disease. Remember, at the foundation of all disease management programs is medical fitness. From the 90-year-old cardiac rehab patient challenged with high blood pressure, to the breast cancer survivor in the Watsu program, to the diabetic, each individual has the potential to thrive, but they will probably enjoy the experience more and have more positive outcomes if they are part of a well-designed medical fitness disease management program.
DISEASE MANAGEMENT-A KEY CRITERIA IN MEDICAL FITNESS CENTER CERTIFICATION
In closing, with the new medical fitness Facility Certification, an excellent opportunity has been created for facilities to evaluate and enhance their clinically integrated models to better serve the chronic disease population. Using the resources provided in the "Medical Fitness Model: Standards and Guidelines" available from the Medical Fitness Association and the review process recommended in this article to identify improvement opportunities, these resources will assist your facility in reaching out to the chronic disease population while also preparing your center for a successful certification process.
Chronic disease is often a lifelong challenge for an individual, but not an impossible summit to overcome. We need to go beyond just telling people what they should be doing and provide well-designed and easily accessible resources so individuals can become empowered to take better care of themselves. If an individual is challenged with a chronic disease, we need to do more from the very beginning, offering the right ingredients at the right time, not slip everything in as an afterthought after we have pigeonholed them into one program, and then call it disease management. Remember, those challenged with chronic disease are the individuals needing the combination of medical fitness and disease management the most. The "Father of Medicine," Hippocrates, even understood and stressed the importance of prevention, "The function of protecting and developing health must rank even above that of restoring it when it is impaired." Wise words that hopefully we can all do a better job of living by, and exciting those around us to also live by.
THE BASIC COMPONENTS OF AN EVIDENCE-BASED CHRONIC DISEASE MANAGEMENT PROGRAM:
1. Identify an important health issue and the population at risk
2. Identify an effective intervention(s)
3. Establish broad-based partnerships that are key for implementation
4. Select a proven evidence-based intervention
5. Translate the intervention into a program
6. Evaluate the program and adjust for improvements
7. Sustain the program
Excerpt from Using the Evidence Base to Promote Healthy Aging, NCOA, Center for Health Aging, 2008.