Disease Management

Population identification processes for at-risk populations and patients who should benefit from disease-specific education. This is accomplished through proactive collaboration with patient and healthcare teams and utilization of predictive analytics.

Managing Population Health initiatives to improve patient outcomes
Identification, tracking, and reporting on top medical diagnosis and Healthcare Effectiveness Data Information Sets (HEDIS) metrics trends
Reduced practice variation and improved care through evidence-base DoD/VA clinical practice guidelines.
Provide information and tools to promote patient-self management activities and education to enhance shared decision-making skills

Disease Management tracks the following

Cancer screening
Chlamydia Screening
Acute Bronchitis (adults)
Diabetes
Low Back Pain
Pediatric (pharyngitis, upper respiratory infection, well child visit)
Mental Health (depression, on medication, follow-up visits at 7 days and 30 days on discharge