Disease Management

What is a disease management model? How can this model be implemented by a behavioral health care provider in a medical setting?

A chronic care (disease management) model (CCM or DMM) is an organizational structure to manage chronic conditions like disease in a primary care setting.

Addressing chronic disease is a major challenge for healthcare systems around the world in working with acute episodic care. DMM seeks to provide organized care for people with long-term conditions. A characteristic of chronic diseases for behavioral healthcare providers is they often require a prolonged period of supervision, observation, or care (Reynolds et al., 2018). The defining features of primary care  in a medical setting (including continuity, coordination, and comprehensiveness) makes this setting suitable for managing chronic conditions.

Evidence  highlights the importance of reorienting health policy and healthcare towards chronic care systems (disease management), including primary care that are initiative-taking rather than reactive (Reynolds et al., 2018). Efforts to improve the degree of public health are conducted by applying various approaches, including involving the potential of the community in disease management with a family approach (Muchtar et al., 2022). In a medical setting, it is noteworthy to periodically evaluate the understanding of disease management so that care for multi morbidity is patient-centered, focused on quality of life, and promotes self-management towards agreed goals.


Muchtar, M., Felnanda, L., Tasman, A., & Agritubella, S. M. (2022). Implementation of family-based disease management model through community empowerment. Media Keperawatan Indonesia, 5(1), 49–57. https://doi.org/10.26714/mki.5.1.2022.49-57

Reynolds, R., Dennis, S., Hasan, I., Slewa, J., Chen, W., Tian, D., Bobba, S., & Zwar., N. (2018). A systematic review of chronic disease management interventions in primary care. BMC Family Practice 19, 11 https://doi.org/10.1186/s12875-017-0692-3


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