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The Indiana Chronic Disease Management Program

jessievenegas Jessie Venegas — 11/01/2009

The Indiana Chronic Disease Management Program (ICDMP) was developed through a joint effort between the Indiana Office of Medicaid Policy & Planning and the Indiana State Department of Health and implemented in June 2003. The program deals with Diabetes, Asthma, Congestive Heart Failure Stroke, AIDS and HIV cases. The goals of the ICDMP: • Build a sustainable comprehensive, locally based infrastructure • Strengthen the existing public health infrastructure • Help improve quality of health care for patients with chronic diseases. The ICDMP focuses on developing linkages between care management and primary care by providing health care providers with tools to better manage chronic care and patients with self-management tools to be more active participants in their health care. The program has the following components: • Call Center for all patients • Nurse Care Management for high risk patients • Collaborative Training for primary care practices • Patient Registry for all patients The ICDMP is a statewide program and includes Medicaid recipients in both primary care case management and risk based managed care.

Diabetes, Heart failure, Asthma, AIDS, Fragility, pluripathology/polipathology and/or complex chronic diseases, Other

Goals Prevention:
Funding for detection programs , Promotes adecuate understanding levels on the community about the importance of prevention , Focuses on social inequalities
Goals Detection:
Promotes early intervention through primary health care measures , Provides registries and patients contact systems , Shows new evidence on the importance of early detection, including guidelines of effective practices
Goals Treatment:
Develop basic elements for an integrated health system , Provides support health policies to facilitate the planning and integration at locally and regionally , Strengthens cooperative local groups to provide integral services , Improving access to health services across the entire spectrum, from prevention to treatment , Ensures the best quality of health services , Promotes the training of health professionals , It facilitates the management by processes , Emphasizes the care of pluri-pathological and fragile patients , Promotes electronic health information systems to improve the quality of care
Goals self-management:
Refocuses the health system to support self-management , Promotes patient involvement in planning services , Improving support services with an emphasis on peer support, the disabled and carers , Allows home care , Allows remote support to patients and their carers from health professionals







Practices Map



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