Critical Pathways as an Essential Part of a Disease Management Program

Disease management is becoming a common tool utilized by health systems for managing patients with chronic diseases. Part of the success of disease management can be attributed to the use of critical pathways. Critical pathways are the tools that prompt decisions to be made based on clinical practice guidelines. In addition to allowing nursing case managers to have significant input into patient treatment decisions, critical pathways assist disease management programs in realizing significant cost savings as well as assisting in outcomes management activities. Key words: case management, clinical practice guidelines, cost savings, critical pathways, disease management, outcomes management. HEALTH CARE has started to undergo rapid changes. The combination of restructured prospective payments and the aging population has forced health care practitioners and administrators to reexamine the methods of health care delivery. One concept of health care delivery that has gained recognition is disease management. Disease management programs are being developed and implemented by health systems in an attempt to manage effectively and economically chronic illness in specific populations. One of the essential components of disease management programs is a critical pathway. This article will chronicle the role of critical pathways in disease management programs. First, concepts of disease management will be reviewed; second, the conceptual and administrative frameworks of the incorporation of critical pathways will be explored; third, the economic concepts of critical pathways and disease management will be discussed; and finally, critical pathways as tools of outcomes management and continuous quality improvement (CQI) will be identified. Nash describes disease management as “a comprehensive, integrated approach to care and reimbursement based on a disease’s natural course. The goal of disease management is to address the illness or condition with maximum effectiveness and efficiency regardless of treatment settings or typical reimbursement patterns.”1(p.4) Ellrodt presents a slightly different explanation of disease management as, “an approach to patient care that coordinates medical resources for patients across the entire health care delivery system. A critical difference between disease management and other approaches to traditional medical care is a shift in focus from treating patients during discrete episodes of care to provision of high quality care across the continuum.”2(p.1687) Disease management programs differ in definition, scope, and intensity from one institution to another and from one program to another. One consistent provision, however, is that disease management programs almost always are aimed at a specific disease condition or specific population. Administrative databases have demonstrated that a small proportion of the population consumes a disproportionate amount of health care resources.2 chronic disease states such as asthma, congestive heart failure, arthritis, and inflammatory bowel disease often are the targets of disease management programs. Although the development and implementation of disease management programs may differ, the eventual goal is always the same. Disease management seeks to provide appropriate, population-based care in an effort to reduce health care expenditures while improving clinical outcomes. Two processes are essential to the formation of effective disease management programs and their accompanying critical pathways. These processes are interdisciplinary collaboration and the application of best practice to the program.2 asthma. The pathway also would evaluate the effectiveness of Mr. R’s treatment by documenting variances from the pathway. It would determine which portions of the treatment plan were not effective. After reading the article address the following questions in 1-2 paged article summary.

What is the function of a clinical pathway?

What ideas from this article apply to this course?

How might you apply the knowledge gained from reading this article in the future?

What is the relationship between clinical pathways and outcomes?

Based on the examples in this article, how might a manager use these findings for decision-making purposes?