Health Dialog Connections

Diabetes Chronic Care Management: New Strategies for Early Interventions

To deliver personalized and cost-effective chronic care management, Health Dialog developed theCare Pathways framework, a stratification methodology that allows us to identify the specific stage of a person’s chronic condition. Each stage requires a unique set of interventions, education and engagement strategies to help every individual improve their health.


We’ve developed the following Care Pathway stages to support chronic care management:

  1. Well – no significant lifestyle risks
  2. At Risk – presence of lifestyle factors that elevate risk for developing chronic disease
  3. Pre-Diagnostic – a combination of lifestyle factors or a pre-diagnosis that represent a high risk for progression to chronic disease
  4. Onset – newly diagnosed with a chronic condition
  5. Early Progressive – presence of early complications
  6. Late Progressive – presence of late complications
  7. Critical Path – high likelihood for a major health event
  8. Sentinel – major health event
  9. Recovery – rehabilitation or recovery from major event

In this blog post, I’ll be discussing how to identify and effectively manage individuals in the early progressive stage of diabetes. We focus on this stage because it is an important opportunity for chronic care management intervention. Providing support at this key stage of diabetes offers the individual tools on how to better manage their condition, and by doing so, slow disease progression and prevent further complications.

Finding those in need of long-term chronic care management

Early progressive diabetes may be identified through key pieces of health information obtained through claims, health risk assessment (HRA), biometric data, or health coach interactions. This data analysis can unlock a wealth of critical information that will inform the intervention strategy:

  1. Type and duration of diabetes. Do they have type 1 or type 2 diabetes? How long have they had diabetes?
  2. Complications. Are they experiencing problems with their eyes or kidneys?
  3. Co-morbid conditions. Have they been told they have high cholesterol or high blood pressure?
  4. Medicines. Do they take insulin to treat their diabetes? Are they taking other medicines?
  5. Specialists. Are they seeing a specialist, such as an endocrinologist or dietitian?

Intervention Priorities and Next Steps for Early Progressive Diabetes

Once the early progressive stage of diabetes has been identified it is possible to provide stage-specific condition education and assign prioritized interventions, tailored to the individual. The top three priorities for an individual in early progressive stage diabetes are as follows:

1. The primary priority is to understand and adhere to their treatment plan. For persons using insulin, the focus is blood sugar management. Educating around the importance of blood sugar control and offering education on how to manage daily blood sugars is essential. This may be enhanced through use of blood sugar trackers, medication reminders, and digital devices or applications.

For individuals with longer term diabetes, education around cardiovascular risk management may be prioritized above blood sugar management. Because diabetes increases the risk for heart disease, education on how to manage high blood pressure and the importance of medication compliance should be emphasized. Patients should also be encouraged to make lifestyle changes, such as eating a heart healthy diet, improving their physical fitness or quitting smoking, to reduce their risks.

2. The next priority for an individual with early progressive diabetes is to follow a schedule ofroutine exams and tests for diabetesas recommended by their healthcare provider, and to understand why these tests are important for effective diabetes care management. Routine tests are critical for keeping diabetes under control, slowing progression of disease and preventing further complications. Examples include HbA1c blood sugar tests; blood pressure and cholesterol screenings; and comprehensive examination of the eyes, feet, and kidneys. It’s important to keep a record of these tests and test results in order to track progress and know when the next scheduled test is due.

3. Finally, the importance of self-care and monitoring should not be overlooked. Individuals in the early progressive stage of diabetes need to understand how to recognize early warning signs and symptoms of complications and what to do, for example with a blood sugar that is dangerously low or dangerously high. They may be directed to printed action plans or to a number of digital health tools or symptom trackers to use as a guide. These tools also serve as excellent records for review with a healthcare provider to adjust treatment plans as needed.

Through careful interpretation of data from health risk assessments, health coach conversations and activity on digital health management platforms, it is possible to identify care pathway stage for individuals with diabetes and direct them to the highest priority interventions for their stage. Interventions may be personalized to meet the individual’s unique needs, addressing their specific barriers and supporting them to reach small, attainable goals that they are most likely to be successful with. By capturing individual motivations and offering specific recommendations, treatments are more effective because the individual has the right tools and information at the right time to properly manage their care.

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