Disease Management Protocol

Initial Assessment
(paper-based - relative to disease)
Biometrics
Medical history assessment
Lifestyle assessment
Medications assessment
Wellbeing assessment

Feedback on biometrics results

Key guidance on medications

Following actions
Scan and email all results to HQ
Book next appointment
Create e-file for member and file results

Management Plan
HQ health professional creates Disease Management Plan
based on scanned results received from pharmacy

Plan emailed to member and copied to pharmacy

Interim engagement
Telephonic support
Member calls HQ call-centre with query
Admin / system queries dealt with at point of call
Clinical queries referred to HQhealth professional

Review Assessment
(paper-based - relative to disease)
Pharmacist reviews members file prior to appointment
Biometrics review
Management Plan review
Key feedback and guidance

Following actions
Scan and email all results to HQ
Book next appointment
File results in member’s e-file
 Book next appointment
File results in member’s e-file

Cycle 1 - monthly (1,2,3)

Cycle 2 onwards - quarterly

Review Report
HQ health professional creates Review Report
based on scanned results received from pharmacy

Report emailed to member and copied to pharmacy

Clinical Governance Hypertension
http://www.acadmed.org.my/index.cfm?&menuid=67
Clinical Practice Guidelines,
Management of Hypertension, 3rd
edition (Malaysian Ministry of
Health, 2008)
Dyslipidaemia
Clinical Practice Guidelines,
Management of Dyslipidaemia, 4th
edition (Malaysian Ministry of
Health, 2011)

Assessment Medical history Personal history Personal history

General General
CVD CVD
Dyslipidaemia Hypertension
Diabetes Diabetes
Chronic kidney diseases
Premature CVD

First degree family history First degree family history

Hypertension Hypertension
Dyslipidaemia Dyslipidaemia
Diabetes Diabetes
Premature CVD Premature CVD

Medications Current prescribed medicines Current prescribed medicines

Current medicine adherence Current medicine adherence
Medicines perceptions and beliefs Medicines perceptions and beliefs

Biometrics Primary metrics Primary metrics

Resting BP Total cholesterol
Resting heart rate HDL
BMI Total cholesterol : HDL ratio
Waist girth measurement LDL
Triglycerides (fasting)
BMI
Waist girth measurement

Secondary metrics Secondary metrics

Total cholesterol Resting BP
HDL Resting heart rate
 Total cholesterol : HDL ratio Fasting blood glucose
Fasting blood glucose

Lifestyle Physical activity levels Physical activity levels

Diet Diet
Alcohol Alcohol
Smoking Smoking Stress
Stress Stress

Monitoring Medications Medicine use review Medicine use review

Medicine perceptions & beliefs Medicine perceptions & beliefs
Obesity Diabetes Asthma
Clinical Practice Guidelines, Clinical Practice Guidelines, Management of Chronic
Management of Obesity (Malaysian Management of Type 2 Diabetes Obstructive Pulmonary Disease,
Ministry of Health, 2004) Mellitus, 4th edition (Malaysian 2nd edition (Malaysian Ministry of
Ministry of Health, 2009) Health, 2009)

Personal history Personal history Personal history

General General General
CVD CVD CVD
Hypertension Hypertension COPD
Diabetes Dyslipidaemia Contraindications to PEF test
Dyslipidaemia

First degree family history First degree family history First degree family history
Hypertension Hypertension Asthma
Dyslipidaemia Dyslipidaemia COPD
Diabetes Diabetes
Premature CVD Premature CVD
Obesity

Current prescribed medicines Current prescribed medicines Current prescribed medicines

Current medicine adherence Current medicine adherence Current medicine adherence
Medicines perceptions and beliefs Medicines perceptions and beliefs Medicines perceptions and beliefs

Primary metrics Primary metrics Primary metrics

Body fat percentage (Visceral fat)
Lean mass percentage
Waist girth measurement
Fasting blood glucose Peak expiratory flow
BMI
Waist girth measurement
Monofilament testing for poor
glycemic control & complications

Secondary metrics Secondary metrics Secondary metrics

Resting BP Total cholesterol None
Resting heart rate HDL
Total cholesterol Total cholesterol : HDL ratio
HDL Resting BP
Total cholesterol : HDL ratio Resting heart rate
Fasting blood glucose

Physical activity levels Physical activity levels Physical activity levels

Diet Diet Diet
Alcohol Alcohol Alcohol
Smoking Stress Smoking Stress Smoking Stress
Stress Stress Stress

Medicine use review Medicine use review Medicine use review

Medicine perceptions & beliefs Medicine perceptions & beliefs Medicine perceptions & beliefs
Operational SOP & Timecosts
Resource time (mins)
HQ Outlet
Registration
Take call from member/policyholder - register details, book initial assessment
Compile welcome pack and despatch (where applicable)
Follow-up call to confirm appointment and receipt of pack (where applicable)

CYCLE ONE - INITIATION

Initial assessment
Meet and greet, biometrics, lifestyle review, medical history review, medications review, counseling, record results 60
Scan and email outputs to HQ 15
Compile management plan and email to member and cc pharmacy 10
Book next appointment
Create e-file for member and file results 5
Pharmacy receive and store management plan 5

Review assessments (x3 - months 1, 2 and 3)

Retrieve member’s electronic file 5
Pharmacist reviews file 5
Meet and greet, biometrics, management plan review 40
Scan and email outputs to HQ 15
Compile review report and email to member and cc pharmacy 5
Pharmacy receive and store review report 5

Interim engagement
Inbound call to call centre - receive call, answer query
Inbound call to call centre - triage to health professional at HQ for response 5

CYCLE TWO - MAINTENANCE

Review assessment
Pharmacy retrieve member’s electronic file
Pharmacist reviews file 5
Meet and greet, biometrics, management plan review 40
Scan and email outputs to HQ 15
Compile review report and email to member and cc pharmacy 5
Pharmacy receive and store review report 5

Interim engagement
Inbound call to call centre - receive call, answer query
Inbound call to call centre - triage to health professional at HQ for response

Total for each 12 week mainten

Total for one year (one initiation cycle and three maintenan
Resource time (mins)
Call Centre Admin Cost (RM)
5

15
5

10

5
r each 12 week maintenance cycle

cle and three maintenance cycles)

Material costs Cost (RM)

Initial assessment form printing

Review assessment form printing
Disease management booklet printing
Equipment
Biometrics consumables
Training - creation of SOP and any hands-on training