How to Improve Disease Management with Comprehensive Medication Management

Published by Sandy Bonfin, PharmD, BCPS on Jun 6, 2022 8:15:00 AM

With more than half of adults diagnosed with at least one chronic condition and 86% of health care costs attributable to chronic illness, the US is in a chronic disease epidemic. While many health plans and providers have implemented disease management programs to improve outcomes for patients with chronic conditions, one important component of disease management, comprehensive medication management, is often nonexistent, ineffective, or unscalable. To improve health outcomes and decrease hospitalizations and cost of medical care, healthcare must improve how it manages medications. This article will examine how to build efficient medication management processes that support disease management.

What is disease management?  

Disease management encompasses a multidisciplinary approach to healthcare delivery for patients with chronic diseases to reduce hospitalizations and improve cost savings and quality of care. According to the Care Continuum Alliance, disease management uses evidence-based guidelines and patient-empowerment strategies for two purposes: 1) supporting the provider-patient relationship and 2) preventing exacerbation and complications associated with chronic diseases.  

Disease management involves:  

  • Creating processes to identify target populations  
  • Following evidence-based guidelines  
  • Creating collaborative practice models between the different members of the care team  
  • Educating patients  
  • Implementing ongoing measurement and evaluation of processes and outcomes  

Conditions that can benefit from disease management include behavioral health conditions, cardiovascular diseases, chronic kidney diseases, diabetes, and respiratory diseases like asthma or chronic obstructive pulmonary disease (COPD).   

Challenges of disease management  

When chronic disease management programs are carefully designed and incorporate multidisciplinary interventions, health plans and healthcare providers can improve their patients' health while lowering their cost of care. Unfortunately, many disease management programs are not successful in reaching those goals. Several challenges can explain this lack of success. 

Program participation and compliance  

Challenges for patients 

Low patient participation and compliance often prevent chronic disease management programs from achieving their full potential. In many cases, poor patient engagement results from communication barriers, including low health literacy, language barriers, and cultural differences. 

Studies have shown that a negative association exists between low health literacy and management of chronic diseases. Only 12% of English-speaking adults in the US demonstrate proficient health literacy. Health organizations often write educational materials in reading levels that are too high for most readers. As a result, patients struggle to understand instructions on how to take their medications, how to monitor their health condition, and when to follow up with their providers. 

Language barriers can also lead to miscommunication between health care professionals and patients, decreasing both patient satisfaction and the quality of healthcare delivery. Additionally, patients from minority communities are more likely than white patients to feel they would receive better treatment if they were a different race or ethnicity and to believe they have been disrespected during a medical visit. Patients who cannot communicate with their doctor or who do not trust their providers may feel reluctant to comply with care plans or even see a doctor for their chronic condition.

Challenges for providers 

Provider engagement can also be a challenge for disease management. Some providers may be apprehensive of attempts to influence their treatment decisions and others may find it challenging to integrate chronic disease management program requirements in their workflow. 

Providers also have limited time to see each patient, and in the short 15 minutes or less that they do have, they may not always have time to implement recommended treatment plan changes, identify any other necessary care plan updates, or follow up comprehensively on the patient’s progress. 

Lack of actionable data  

Health plans have access to a considerable flow of data, yet often much of this data is barely usable. If clinicians cannot quickly glean insights or understand the next action or intervention each patient needs from the data, they will be unable to scale care to serve large populations.    

care giver providing care for a person with a chronic conditionsWhat can CMM do for disease management?

Comprehensive medication management programs are uniquely positioned to improve disease management. Care teams providing CMM perform regular interventions either in person or via telehealth and can use these patient touchpoints to support a patient as they manage their chronic condition. 

Optimize medication therapies   

Tackling chronic diseases requires optimizing medication therapies for patients. Patients with chronic diseases are more likely to experience polypharmacy which exacerbates their disease symptoms, increases mobility issues and increases the risk of inappropriate medication use and non-adherence to medication.  

Care teams providing comprehensive medication management services can decrease polypharmacy by optimizing patient medication regimens and recommending the discontinuation of inappropriate medications. They can also ensure that patients have access to their medications by arranging for delivery or more refills (e.g., 90-day supply instead of 30-day) and decrease the cost of medications by recommending more affordable options.  

Recommend lifestyle changes

Clinicians providing medication management are well-positioned to counsel a patient on lifestyle changes, another critical component of chronic disease management. They have access to the patient’s medical history and by asking relevant questions, they can identify areas where the patient needs support and education.  

Educate patients about self-management

In addition to implementing lifestyle interventions, empowering patients to take control of their health is also an important tool of disease management that can improve quality of life. During medication counseling, the comprehensive medication management care team can also counsel patients on how to manage their condition. For instance, in a diabetes management program, the CMM care team can counsel a patient with diabetes with self-care strategies like how to use their blood sugar monitor and what to do in case of severe hypoglycemia along with providing medication counseling. 

AI-powered CMM to support disease management

Traditional disease management is time-consuming, involving hours of care team time reviewing registries of individuals, understanding each person’s needs, and systematically reaching out for intervention. Disease management today needs to be nimble, prescient. To scale this level of care to large populations, care teams need to harness the power of artificial intelligence and machine learning to efficiently identify high- and rising-risk patients and deliver the right care at the right time. 

Predictive analytics 

Arine analyzes clinical, social, and behavioral data to identify and target high-risk patients. Once Arine has synthesized the data and identified high and at-risk patients, it triggers an intervention with precise recommendations for the CMM care team. This approach allows the care team to focus on the right patients at the right time, preventing patients from slipping through the cracks. 


Once Arine has identified the right patients, it automatically builds an evidenced-based care plan that the care team uses when they deliver care. Care teams have all the patient data insights and clinical guidelines they need at their fingertips, allowing them to focus on the patient instead of needing to dig for the right information. 

Machine learning  

Finally, Arine measures the outcomes of each intervention and feeds its findings back into future care plans to provide care teams a recommendations engine built for the unique needs of their population. This allows disease management programs to continually improve and scale faster.   

Change can’t wait. 

The number of patients with chronic disease continues to increase and without a scalable solution to improve disease management, costs and poor patient outcomes will rise with each diagnosis.  As health plans and providers deliver care to patients with chronic conditions, AI-enabled comprehensive medication management can address challenges care teams encounter to help patients achieve their personal goals of therapy. 

Learn how CMM can improve outcomes and reduce cost of care in our on-demand webinar. 

On-demand webinar. Medication Optimization: the Missing Link in Value-Based Care. Register Now.

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