Disease Management Program for Chronic Diseases

Chronic diseases are the leading cause of death and disability in the United States. In fact, chronic diseases are responsible for seven out of every 10 deaths in the U.S., killing more than 1.7 million Americans every year.[1] Chronic diseases are ongoing, generally incurable illnesses or conditions. Congestive heart failurechronic obstructive pulmonary disease (COPD), asthma, cancer, and diabetes are among the most pressing chronic diseases facing our society and healthcare system today. Chronic diseases can dramatically reduce a person’s quality of life, especially if left undiagnosed or untreated. At present, 133 million Americans – 45% of the population – have at least one chronic disease.[2]

The Staggering Financial Cost of Chronic Diseases in the U.S.

  • People with chronic conditions are the most frequent users of health care in the U.S. They account for 81% of hospital admissions; 91% of all prescriptions filled; and 76% of all physician visits.[3]
  • Chronic diseases also account for the vast majority of health spending. In the U.S., total spending on public and private health care amounted to approximately $2 trillion during 2005.[4]
  • Of that amount, more than 75% went toward treatment of chronic disease.[5]
  • In publicly funded health programs, spending on chronic disease represents an even greater proportion of total spending: more than 99% in Medicare and 83% in Medicaid.[6]

Chronic Disease Management is Challenging in the Current Healthcare System

Our current healthcare system was designed to address acute illness rather than chronic disease. However, due to its present epidemic proportions, chronic disease management is absolutely critical in today’s healthcare environment.

Lessening the devastating toll chronic diseases are having on millions of lives in our country, requires a paradigm shift in perspective from previous models of healthcare that treated patients only when they were unwell or when a problem arises. As the U.S. healthcare industry transitions from ‘volume’ to ‘value’, providers are increasingly expected to become more invested in promoting their patients’ overall health, preventing disease, injury, disability, and ensuring continuity of care across providers. In short, now is the time that providers will need to find new avenues to develop patient-centered approaches versus being symptom focused.

For both patients and providers, managing chronic diseases are often difficult and the complexity increases when those that are suffering from Multiple Chronic Conditions (MCC) are involved. However, interventions to reduce risk factors and prevent chronic disease have proven to be extremely successful. By detecting chronic disease early, and rapidly intervening to prevent its progress, there is significant potential to improve patients’ quality of life and reduce deaths from chronic disease.

Fonemed’s Disease Management Program Combats Chronic Disease

Although chronic diseases are among the most common and costly health problems facing Americans, they are also among the most preventable. Given the right treatment and support, people diagnosed with a chronic disease can improve their health and quality of life.

Since chronic diseases are an ongoing illness, they require a pro-active, planned, integrated care approach within a system that clients can easily navigate. Accordingly, Fonemed has developed a unique Disease Management Program that squarely addresses these needs. Fonemed’s Disease Management Program consists of a collaborative partnership between a Registered Nurse and patient, resulting in a cost‐effective, patient‐centered and personalized approach to manage their chronic condition(s) and reach their optimal level of health and quality of life.

Disease Management Program Goals Overview

Using medically approved guidelines and industry best practice standards, our specially trained Nurse Counselors complete a general and disease‐specific and/or mental health assessment via telephone and, based on the patient responses, create a plan of care in coordination with the patient. Continual assessments can identify actual/potential gaps in care and provide appropriate recommendations. The patient’s progress and action plan is reviewed at each encounter and goals/interventions are updated as needed. Additionally, self‐management strategies are developed to help the patient adapt to illness, adhere to treatment, identify and change unhealthy behaviors, as well as recognize and avoid high risk situations. Additionally, Remote Patient Monitoring (RPM) technologies can also be incorporated into a disease management program. Continuous monitoring afforded by these technologies and Fonemed’s Population Health Platform can provide the critical insights for clinical staff to make adjustments to the patient’s health plan and produce better health outcomes.


  • Optimize a patient’s health and minimize symptoms
  • Deliver reliable and effective care coordination
  • Guide theme to appropriate care when needed
  • Empower patients to take greater responsibility for their own health
  • Increase a patient’s independence
  • Enable remote chronic disease management
  • Improve and manage care transitions
  • Reduce avoidable ER visits and hospital re-admissions
  • Keep beneficiaries well and offer behavioral counseling

Patient Clinician Relationship

Fonemed’s Disease Management Program is a proactive approach to chronic disease management that encourages ways to build health promotion and disease prevention into healthcare practice and the lives of our clients. We use patient-centered motivational interviewing techniques, that assist our patients in identifying effective strategies to increase their motivation and confidence level to the point of positive behavior change. Throughout this process, the Registered Nurse acts as an educator, coach, and partner, as well as offers resources and referrals on a variety of health‐related subjects to the patient.

Connecting Providers and Coordinating Care

An effective disease management program requires multi-faceted care which, at times, calls for clinicians and non-clinicians from multiple disciplines to work closely together, to meet the wide range of needs of the chronically ill. An individual’s Healthcare Provider will be an active participant in the care of the member through collaboration with the Nurse Counsellor and through direct member contact. Patient progress towards their self‐management/treatment plan is regularly evaluated using outcome measures. Provider partners can expect to see patient engagement rates improve as their patients take a much more active role in maintaining and improving their own health.

Improving follow-up care, and ensuring that the patient is engaged with that care, has benefits across the entire healthcare spectrum. Fonemed’s clinical staff actively engages with patients suffering with one or more chronic conditions and can share data and provide feedback with designated caregivers and providers. Access to patient data and related resources can be provided as appropriate through our population health management software. Providers are able to view, track and manage critical metrics associated with a member population. Improving communication among providers ensures the appropriate disease management processes and resources are actively maintained, regularly reviewed and updated according to member’s needs.

Why Partner with Fonemed for Your Organization’s Disease Management Program?

Despite these startling statistics surrounding chronic diseases, these diseases are often preventable, and frequently manageable through early detection, improved diet, exercise, and appropriate treatment. As a telehealth industry veteran, we’ve created pioneering programs focused on quality of care and patient satisfaction that can be delivered cost effectively to remote patients using technology including our Disease Management Program. We strive each day to enhance the lives of the people we serve by providing knowledge and positive interactions that seek to create a healthier future for all.

Is your organization looking for an experienced partner to help your healthcare organization better manage the health of your members? We’re here to help. Contact us today.



1:Centers for Disease Control and Prevention. Chronic Disease Overview page.
Available at: https://www.cdc.gov/cdi/

2: Wu S, Green A. Projection of Chronic Illness Prevalence and Cost Inflation.
RAND Corporation, October 2000.

3.Partnership for Solutions. Chronic Conditions: Making the Case for Ongoing
Care. September 2004 Update. Available at: https://www.rwjf.org/en/library/research/2004/09/chronic-conditions-.html

4.Centers for Medicare and Medicaid Studies. Historical Overview of National
Health Expenditures. Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/index?redirect=/NationalHealthExpendData/02_NationalHealthAccountsHistorical.asp#TopOfPage

5.Centers for Disease Control and Prevention. Chronic Disease Overview page.
Available at: https://www.cdc.gov/cdi/

6.Partnership for Solutions. Chronic Conditions: Making the Case for Ongoing
Care. September 2004 Update. Available at: https://www.rwjf.org/en/library/research/2010/01/chronic-care.html