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From The Issue Editor

The goal of this issue is to provide a forum for cross-fertilization of knowledge and ideas regarding disease management (DM). The issue authors include multidisciplinary authors from traditional home health care (HHC) and mature DM providers, health researchers and leaders from government and community-based advocacy groups dedicated to chronic care improvement. It was gratifying to hear the authors verbalize regarding their rich learning experiences in the issue development. This occurred during the research, editing, and dialogue exchange process regarding home care and DM issues and ideas to develop the best possible issue to a diverse readership. The authors are knowledgeable regarding the shift in demographics and health options that will deliver exponentially larger populations of patients who are frail, elderly, and chronically ill that live longer in their disease trajectories. HHC providers have collaboratively developed some DM program components with referral sources, such as hospital and community-based providers. These models for delivery involved traditional visitbased care, follow-up phone coaching and support, and some involved telehealth pilots, call center and webbased data integration; minimum data set (MDS), population-based data mining and risk analysis; drug utilization review and other patient safety enhancements (PSE). HHC is evolving to meet population demographic changes, regulatory requirements for performance improvement (PI), and adverse events reduction and to succeed in a prospective payment system (PPS) environment. HHC has experienced extensive consolidation and challenges and has adjusted to meet the challenges of aggregate outcome data benchmarking in the public domain. Innovative HHC and DM partnerships are emerging as the Center for Medicare and Medicaid Service (CMS) pilot projects (Medicare Health Support [formerly Chronic Care Improvement Program]). The Disease Management Association of America (DMAA) has illuminated mature DM program components and standardized outcomes tracking methodologies via education programs, publications, public policy advocacy, and research (www.dmaa.org). The DM industry evolved embracing the health promotion (illness prevention), proactive complex care management, and continuum of care concepts championed in mature health markets the 1990s. In these markets, illness and disease progression prevention and evidence-based (EB) protocols were financially incented. The delivery model for these programs integrated remote care management telephonically and via other telehealth forms, call centers, mailed education, health screening, and other Web-based applications. DM providers developed sophisticated data mining, predictive risk mining, risk-based interventions, and appropriate outcomes assessment methodologies. Interdisciplinary DM has evolved to consistently provide proactive, E-B care management across the practice settings. The goals are improved empowerment of patients in self-care preventing avoidable rehospitalization and other adverse events. Similar to the 100,000 lives campaign (joint Institute of Medicine and Institute of Healthcare Improvement initiative for inpatient care) reduced morbidity and mortality and excessive cost are also goals. The right care, at the right time, in the right setting is facilitated via effective, timely interdisciplinary collaboration and innovative technology and E-B protocols integration in DM. Elizabeth Heckinger, Heather Chappell, Dorothy Downes, and Karen Fitzner of DMAA have illuminated the DM-related home care safety research. This innovative and comprehensive “Mid-Decade Evolution Toward Patient Safety” manuscript addresses the problems of safety, affordability, and patient satisfaction. Patient safety within chronic DM is illuminated by the authors as having moved from the conceptual stage to a definition stage with “cataloguing” of best practices being established. The research progres-