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:

Points of Engagement

Program Outcomes

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
Our clients have a primary care no call/no show rate of just 2%
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
0% lower
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
ER utilization across all of our programs averages 4.3 ER visits per 1000 clients per month
The in-patient admission rate of diabetes care management program is .09 admissions per 1000 clients per month