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 Dyslipidaemia
http://www.acadmed.org.my/index.cfm?&menuid=67
Clinical Practice Guidelines, Clinical Practice Guidelines,
Management of Hypertension, 3rd Management of Dyslipidaemia, 4th
edition (Malaysian Ministry of edition (Malaysian Ministry of
Health, 2008) 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) Fasting blood glucose Peak expiratory flow
Lean mass percentage BMI
Waist girth measurement 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
