Chronic Disease Self-Management

Chronic disease is a public health issue affecting 35% of all Medicare beneficiaries who have at least one chronic condition.

Our clinical and quality improvement experts are here to support you and your practice with:

• Improving access to patient self-management program to improve health outcomes
• Tracking and reporting of MIPS® quality measures
• Impacting measures to improve cardiac health and reduce unplanned hospital admissions in persons with multiple chronic conditions and all-conditions readmissions
• Increasing identification of behavioral health comorbidities that impact physical health outcomes

Goals

• Assist clinicians with creating efficient workflows to harness HIT capabilities to screen for, diagnose, and manage chronic disease
• Empower patients by teaching self-management techniques to control disease
• Prevent the potential progression to more serious and life-threatening conditions

Latest News

Technical Assistance

• Promote Million Hearts® Initiative
• Support with tracking and reporting MIPS quality measures
• Increasing access and referrals to diabetes education programs
• Incorporating Trauma-Informed Care, depression and anxiety screening, substance use disorders screening, and social determinants of health screening

Patient Education

• Support the creation of sustainable community self-management programs about diabetes and chronic disease
• Improving access to non-pharmacological interventions to help decrease opioid use for Medicare beneficiaries living with chronic pain

Practice Education

• Facilitating clinical decision making and patient education
• Benchmarking and comparative feedback data reports
• Educational resources for clinicians, staff, patients, and residents
• Access to dashboards displaying your data for comparative and feedback within your service area.

Our clinical and quality improvement experts will share tools and resources on:

• Cardiovascular Health 
• Prediabetes and Diabetes
• Chronic Pain
• Chronic Kidney Disease