For the purposes of this chapter, âdisease management programs and servicesâ means services administered to patients in order to improve their overall health and to prevent clinical exacerbations and complications utilizing cost-effective, evidence-based, or consensus-based practice guidelines and patient self-management strategies. Disease management programs and services shall contain all of the following: (a) A population identification process. (b) Evidence-based or consensus-based clinical practice guidelines, risk identification, and matching of interventions with clinical need. (c) Patient self-management and disease education. (d) Process and outcomes measurement, evaluation, management, and reporting.
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