Chronic Care Management

According to the Centers for Disease Control and Prevention (CDC), chronic diseases, such as cardiovascular disease, chronic obstructive pulmonary disease (COPD), diabetes and asthma, affect six in 10 U.S. adults and account for 90% of all healthcare costs.^{1, 2}

Health Dialog’s Chronic Care Management solution addresses the problem with a NCQA-accredited Population Health program that provides personalized interventions to help individuals better manage chronic diseases and reduce costs. Health Dialog has years of experience implementing care management programs that get results.

We use the Pathways Engine, our predictive analytics and machine learning platform—which utilizes over 600 data points, incorporating medical and prescription claims history and socio-economic factors—to select the most appropriate members to target. Our Care Pathways framework positions individuals along a disease trajectory, from first being diagnosed with a condition to being at serious risk for a critical event and all of the stages in between. We support members along four major Care Pathways—cardiovascular, diabetes, asthma and COPD, pinpointing which stage an individual is at in their healthcare journey in order to tailor clinical interventions and action plans to address the member’s needs.

Components of our Chronic Care Management solution include:

• NCQA Population Health Accreditation
• Powerful healthcare analytics, using our Pathways Engine to stratify your population based on key risk indicators
  
• Multi-channel engagement campaigns via phone, mail, email, text, web chat or interactive voice recognition (IVR) 
• Whole-person health coaching focused on reducing care gaps, improving clinical outcomes and reducing unnecessary healthcare spending
• 24/7 inbound telephone access to our Health Coaches for urgent, acute and self-care needs
  
• Post-hospital discharge outreach to help avoid unnecessary readmissions
• Shared decision making tools to educate and guide members on treatment choices and condition management
• Health education tools, including online and print materials and an audio reference library
• Comprehensive reporting on clinical and financial outcomes, member satisfaction and operational metrics