"Treat to Target": Disease Management on Steroids

Writing in the latest issue of the American Journal of Managed Care, medical student David Margolius and academic scholar Thomas Bodenheimer describe an approach to hypertension management called "Treat to Target."

It has three ingredients:

1. Home blood pressure monitoring and recording

2. "... regular phone calls from a nonphysician team member who reinforces blood pressure goals and provides coaching on diet, exercise, and medication adherence. These team members—also referred to as health coaches—may be registered nurses, pharmacists, medical assistants, or other nonclinicians trained in behavior-change counseling."

3. Standing physician orders, which can be jointly used by the coaches and the patients to up doses are start new medications.

The authors quote several peer-reviewed studies that have shown it works. The secret sauce, they say, is making physician instructions understandable to patients, bringing them into the decision making, improving low medication compliance rates and overcoming clinical inertia.

The DMCB likes the idea because it takes the disease management coaching model (already in place in about 20% of all patients with a chronic condition nationwide) and gives it an additional punch. While physicians and policy makers may tut-tut about the potential to undercut the doctors' role, the fact is that "standing orders" are one of the great secrets of countless well-run clinics and, if done right, fall well within scope of practice laws in most States.

As typical of most academicians nowadays, Dr. Bodenheimer suggests all that is needed is insurer coverage of home monitoring and payment for the accompanying physician effort. The DMCB suggests these ingredients are necessary but not sufficient. Another resource is the disease management vendors. They've probably been thinking on how to systematize something like this across a network while simultaneously preserving the individual physician-patient dyad.

Finally, why stop at hypertension? This could also work in diabetes mellitus and hyperlipidemia.

Now that we have an scholarly article that links standing orders and disease management, the DMCB hopes its vendor-colleagues are printing out that article and approaching its buyer/purchaser/insurer customers with the next step up population care management. Hopefully, all of us will get to read about those outcomes in a future issue of AJMC.