Disease Management

This mandatory standard (like so many URAC medical management mandatory standards) is designed to insure that no non-clinical staff members are engaged in any activities that should be done only by clinicians.  Further, it requires that clinicians perform only those clinical tasks that are appropriate to the scope of their respective licenses.   Finally, it calls for appropriate supervision of non-clinical staff members by licensed clinicians.

The standard reads:

The disease management program defines the allowable scope of activities for licensed or certified clinical staff and non-licensed or non-certified non-clinical staff in carrying out its disease management activities that:
(Primary)

    (d) Provides for supervision of non-clinical staff in the disease management program by licensed or certified staff. (Primary)

This standard can be supported with a variety of types of documentation at the desktop review stage: job descriptions, policies and procedures, and attestations about working within the scope of licensure are the most common.  On the other hand, the onsite review will focus on the knowledge of staff members of the requirements of this standard.   

This standard, which bears a scoring weight of 4, provides:

The disease management program establishes and implements policies and procedures to promote consumer decision-making that specify: (Secondary)

(e) Circumstances under which a family member/legal guardian may be asked to give consent or provide to/receive information from the disease management program. (Secondary)

This standard has a wide reach, covering such decision support tools as educational videos and brochures, Web sites, and information delivered in-person. The communication suggested by this standard, it should be noted, is a collaborative one, not a one-way flow from the DM organization to the consumer, as reflected in subsections (c) and (d). Further, because nothing happens in URAC-land unless it is documented, it is incumbent on the organization to have a mechanism to record the process of collaborating with consumers to establish and monitor the consumer's health goals.

It would be important to make sure that any changes in consumer-directed decision support tools, such as the addition of a new brochure, or Web-based education campaign, be reflected in the DM program documentation. Therefore, any process of periodic review of that documentation should include an assessment of whether it is up-to-date regarding such decision tools.

Subsection (e), as the interpretive information makes clear, is for minors or other consumers without the legal or clinical capacity to make decisions regarding their health care without assistance. The DM program documentation must foresee this possibility and provide a mechanism in anticipation of that eventuality. This documentation should be consistent with the program's HIPAA guidelines, and therefore should be coordinated with the compliance department.

This standard, which carries a scoring weight of 4, provides:

The disease management program establishes and implements procedures for communicating with treating providers and their representatives in a collaborative manner regarding care of participating and/or eligible consumers that includes:
(Primary)

    (c) Information on rights and responsibilities of providers whose patients are participating in the disease management program. (Secondary)

As usual, the documentation begins with a P&P that describes the organization's approach to communication and collaboration with the treating provider.  This is true even if the primary communication is through the consumer -- the P&P still must describe this approach.  The P&P should describe in some detail how, when, and by what mechanisms information will be communicated to the provider.  This should include the mechanism for notifying the provider of a critical healthcare incident that the consumer might face.  A key test of the adequacy of the provider outreach is whether he/she is receiving enough information to identify the DM program and to access that program.

Document needed for the desktop review stage is simply a combination of the appropriate P&Ps and the staff training protocols.  The onsite review will focus on staff interviews and any documentation of provider outreach to verify implementation of this standard. 

DM 3, which carries a weight of 4, provides:

The disease management program develops and updates its scope of service, including clinical interventions, with the guidance of actively practicing providers and content experts with expertise in the relevant clinical condition(s). (Primary)

This standard complements the requirement of DM 2 to keep guidelines up-to-date with the help of clinical experts by requiring a similar effort regarding interventions. As is the case with DM 2, DM 3 requires the involvement of clinical experts appropriate to each of the DM programs.

The documentation required for the desktop review phase includes a list of clinical experts, along with their CVs, used in reviewing and updating its interventions. Documentation at this phase also should include minutes that indicate their attendance at appropriate meetings.

During the onsite phase, in addition to reviewing the documentation submitted during the desktop review phase, the URAC reviewer will talk to clinical leadership -- including the clinical experts that are the subject of this standard -- to confirm that the experts were indeed involved at the level they need to be involved to fulfill the intent of this standard.

DM 2 provides:

Disease management practices for each clinical condition are based on scientific evidence and includes input from clinical content expert(s) one of which must include a provider in the specialty area, that:
(Primary)

    (e) If the program guidelines are modified, a content expert with expertise in the relevant clinical condition(s) must review the guidelines. (Primary)

This mandatory standard is comprised of primary elements, which means that an applicant must get all of the elements of this standard right in order to have a chance at a full accreditation.

Naturally, evidence for this standard begins with having a P&P that outlines the entire process described by the standard, plus minutes from meetings demonstrating implementation.  The content expertise of the provider(s) providing input will need to be thoroughly documented, as will the fact and nature of his/her input in the review process.

Note that, where the guidelines are not based on clinical consensus, the scientific methodology used to establish those guidelines will need to be documented.  The literature cannot be cursory -- URAC requires that it be "comprehensive."  

Mechanisms for sharing the guidelines are essential to this standard.  The applicant must show not only that they exist, but also that they have been used.

The qualifications of the provider(s) providing input will be tested both during the desktop review and in the onsite review process, including an interview (possibly by telephone) of the expert(s).  The expert need not be an MD, but certainly should be deeply qualified in the particular domain involved. 

The first Disease Management standard provides:

The disease management program establishes and implements policies and procedures that at a minimum address:
(Secondary)
(a) The scope of disease management services for each clinical condition; (Primary)
(b) How the disease management program works collaboratively with providers to promote evidence- based practice; (Primary)
(c) How the disease management program promotes consumer self-management and informed medical decision-making; and (Primary)
(d) How the disease management program evaluates its outcomes. (Primary)

The standard carries a scoring weight of 4, and therefore is important but not mandatory.

The documentation required for this standard can be rather straightforward: applicants should submit a detailed description of the program -- its scope, implementation, relationship to other entities within and outside of the organization, and methods of program evaluation.  An organization chart at the DM program level also will be helpful to the reviewer as she begins to acquaint herself with the organization.

As an orienting document for the reviewer, it will be important that the program description detail which disease states are the subject of the DM program.  Furthermore, if the applicant is seeking URAC accreditation for some DM programs but not others, it should specify that in the notes submitted on AccreditNet with the program description.

Note that the Interpretive Information/Commentary is quite specific in defining what is meant by "scope of services" in subsection (a): "the clinical and non-clinical interventions offered by the disease management program for each condition."  The commentary adds the helpful hint: "Interventions may include health education, training on medication compliance, health promotion including lifestyle modifications, responsive or proactive health advice, home or clinic based monitoring, case management, triage or other services."

Similarly, the commentary is helpful regarding the collaboration requirement of subsection (b): "Collaborative approaches may include assisting consumers to communicate more effectively with their treating providers, offering providers information on the disease management program on request, involving providers in program development and updates, and providing feedback on individual performance as necessary."

The onsite reviewer will not spend much time on this standard, specifically.  She will assess compliance primarily through interviews with DM staff members, making sure that what they tell her is consistent with what the program description says.