Chronic Disease State Management Programs

Disease State Management (DSM) programs will be based on evidence-based guidelines and include:

Disease state education of patient

  • Causes of disease and risk factors
  • Consequences of not treating disease or undertreating disease
  • Educational materials and resources provided to the patient
  • Training materials and supplies needed by the pharmacist to use with a patients such as blood glucose monitors, blood pressure cuffs, inhaler demo units, etc.

Assessing current status

  • May include obtaining lab test results from providers or other measurements
  • Equipment and supplies needed if pharmacy is performing tests or assessments

Establishing patient specific goals

  • Using established criteria or benchmarks

Addressing medication issues and adjustments

  • Communication with other health care providers
  • May include collaborative practice agreements

Developing a care plan

  • Identifying barriers to compliance
  • Individualized to the patient
  • Includes non-medication actions to improve disease state or lower risk factors such as dietary management, smoking cessation, weight loss, vitamin supplements, meditation, deep breathing, or other strategies as appropriate to the disease state and the individual patient

Monitoring disease state and progress towards goals

  • Appropriate follow up and lab work or testing
  • Additional medication changes, additions, or adjustments
  • May be self-monitored and managed, if appropriate

Documentation of each step in the process

  • As with medication management programs, each visit with or follow up call to the patient, other health care providers, etc.


Common DSM programs including types of equipment needed (and if additional certification such as a CLIA waiver is needed) if the pharmacy is monitoring or assessing progress: (including equipment maintenance and calibration and appropriate training of staff including CPR or BBP where indicated)

  • High Blood Pressure: Blood pressure cuff/stethoscope, scale for weight monitoring (if appropriate)
  • Hyperlipidemia: Cholestech or other machine that uses blood to determine lipid levels. May also include liver function tests.
  • Diabetes: Blood glucose monitor, A1c monitor (also uses blood), may include scale for weight monitoring, measuring lipid levels with Cholestech (uses blood), and blood pressure monitoring, training materials and equipment such as insulin delivery devices, glucose monitors, etc.
  • Anticoagulation Services: Equipment to measure INR (uses blood)
  • Asthma: Peak flow meter, training equipment such as inhaler demo units, spacers, peak flow meters, nebulizers