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Disease Management, Case Management, Care Management, and Care Coordination: A Framework and a Brief Manual for Care Programs and Staff

Ahmed, Osman I. MD, DrPH, FAAFP

doi: 10.1097/NCM.0000000000000147
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With the changing landscape of health care delivery in the United States since the passage of the Patient Protection and Affordable Care Act in 2010, health care organizations have struggled to keep pace with the evolving paradigm, particularly as it pertains to population health management. New nomenclature emerged to describe components of the new environment, and familiar words were put to use in an entirely different context.

Purpose/Objectives: This article proposes a working framework for activities performed in case management, disease management, care management, and care coordination. The author offers standard working definitions for some of the most frequently used words in the health care industry with the goal of increasing consistency for their use, especially in the backdrop of the Centers for Medicaid & Medicare Services offering a “chronic case management fee” to primary care providers for managing the sickest, high-cost Medicare patients.

Primary Practice Settings: Health care organizations performing case management, care management, disease management, and care coordination.

Findings/Conclusions: Road map for consistency among users, in reporting, comparison, and for success of care management/coordination programs.

Implications for Case Management Practice: This article offers a working framework for disease managers, case and care managers, and care coordinators. It suggests standard definitions to use for disease management, case management, care management, and care coordination. Moreover, the use of clear terminology will facilitate comparing, contrasting, and evaluating all care programs and increase consistency. The article can improve understanding of care program components and success factors, estimate program value and effectiveness, heighten awareness of consumer engagement tools, recognize current state and challenges for care programs, understand the role of health information technology solutions in care programs, and use information and knowledge gained to assess and improve care programs to design the “next generation” of programs.

Osman I. Ahmed, MD, DrPH, FAAFP, is a family physician epidemiologist and NCQA surveyor. Currently, he is a Consultant Physician, Analytics and Managed Health Care in Clearwater, FL. His prior positions include Chief Medical Officer for Magellan Complete Care and Amerigroup Inc. in Florida, National Medical Director, Senior Regional, and Regional Medical Director, United Health Group. Throughout his career, he has developed, implemented, and lead several care management programs.

Address correspondence to Osman I. Ahmed, MD, DrPH, FAAFP, 13672 Eagles Walk Dr, Clearwater FL 33762 (ozzieahmed@gmail.com).

The author reports no conflicts of interest.

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