Disease Management Programs

Tufts Medical Center's multidisciplinary approach to medical care includes aggressive disease management programs, which educate, monitor, motivate and empower patients with tools and techniques that aid in disease prevention and health maintenance. Tufts Medical Center's disease management efforts are especially strong in cardiovascular care, oncology, pediatric specialties and transplantation services.

Disease management examples at Tufts Medical Center include:

• Tufts Medical Center has also developed a unique, community-based management program for patients with heart failure, called Specialized Primary and Networked Care in Heart Failure (SPAN-CHF). Through this program, Tufts Medical Center physicians and nurse practitioners, along with referring physicians, are linked to a specialized database dedicated to the ongoing management of a panel of heart patients. This allows for improved data access and communication across various healthcare sites, reduced hospitalizations through more rapid response at outpatient sites -- including home -- and continuous monitoring capabilities.

• In transplantation services, approximately 10 percent of the patients referred to Tufts Medical Center for chronic liver diseases -- including autoimmune chronic hepatitis, primary biliary cirrhosis and primary sclerosing cholangitis -- can be managed medically, even though they were referred to the Medical Center for liver transplantation. Half of these patients never require a transplant at all, while the other half can continue for three to 10 years before needing a transplant.

• Medical management in the area of serious renal diseases includes both pre-and post-transplant care, including early identification of serious kidney problems and ongoing management of medications that are prescribed to maximize native kidney function, ward off infection or prevent organ rejection, but which can also have substantial side-effects.

• Adult and pediatric oncology patients have access to disease management through the multidisciplinary care provided at The Cancer Center at Tufts Medical Center. The Medical Center offers a complete array of treatments for cancer, with a full complement of physicians managing each patient's individual case. Tufts Medical Center physicians from specialties such as radiation oncology, radiology, medical and surgical oncology, pediatrics, infectious diseases, neurology and urology, as well as members of the Medical Center's Department of Social Work Services, all work to coordinate care.