Chronic Disease Self-Management

Improving Cardiac Health, Diabetes Care, and Chronic Kidney Disease Care

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


  • 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

Clinical and Quality Improvement Offerings

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.

Highlighted Tool and Resources

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

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

For Questions and Support