Our chronic disease care management services are designed to assist our partners achieve their quality measure, utilization, and financial goals by incorporating clinical care coordination, socioeconomic case management, health literacy education, and disease self-management education and support together into one seamless package.

Our programs have been proven to reduce unwanted and unnecessary utilization such as ER and in-patient admissions while increasing patient compliance and improving healthcare outcomes. Our programs are not one size fits all but instead are tailored to the meet the needs of individual patients and target populations through the use of comprehensive needs assessments and population analysis.

Primary Program Goals

The success of our chronic disease care management programs are based upon a singular focus on achieving the following goals:

Relationship Building

create and maintain positive working relationships with our clients built upon the ideal of mutual trust and respect

Patient Centered Care Plan

work with the client, the client’s family and caregivers, and the client’s providers in the development of a patient centered care plan

Primary Care

ensure the client adheres to their primary care treatment plan including attending all prescribed visits

Specialty Care

ensure the client adheres to their specialty care clinical treatment plan including the attendance of all prescribed visits

Medications and DME

ensure the client adheres to their prescribed medication and DME regimen

Diagnostic Testing and Screenings

ensure the client obtains all necessary diagnostic tests, screenings, and vaccinations in the appropriate timeframe

Self-Management and Health Literacy Education

ensure the client obtains the education and skills necessary to become effective self-managers of their primary diagnosis and any related co-morbidities

Socioeconomic Needs

ensure the client gains access to the services and resources they need to become and stay healthy

Points of Engagement

Initial Engagement

the initial engagement is done in-person at the provider’s office and focuses on relationship building and completing a risk/needs assessment.

Supportive Engagements

supportive engagements are done at pre-prescribed times and allow us to engage the client in a comprehensive and holistic way. We engage high risk clients at least once a month with a focus on relationship building, reassessing and making appropriate modifications to the care plan, and providing self-management education and support. Whenever possible these supportive engagements will take place in person at the provider’s office to assist in the care planning process.

Dynamic Engagements

dynamic engagements happen as needed to provide coordination of the clinical treatment plan and socioeconomic case management.

Program Outcomes

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Our chronic care management program has achieved a 98% treatment plan compliance rate with regards to diabetes related primary care, specialty care and diagnostic testing
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Our clients have a primary care no call/no show rate of just 2%
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82% of the clients in our diabetes management program have shown improvement with at least two health indicators such as A1C, blood pressure, cholesterol and body mass index
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According to a study completed in partnership with Community Health Alliance, a local federally qualified health center, clients in our diabetes management program showed better health outcomes than a co-hort group of similar patients. A1C levels were 16% lower than the co-hort group, total cholesterol was 11% lower, body mass index was 17% lower, and blood pressure was 13% lower
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ER utilization across all of our programs averages 4.3 ER visits per 1000 clients per month
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The in-patient admission rate of diabetes care management program is .09 admissions per 1000 clients per month

For more information about our care management programs and how we can help you achieve your organizational goals.

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