Care Management/ Care Coordination/ Chronic Disease Management
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Chronic Disease Management

Monitor disease registries, program enrollment, compliance, and clinical outcomes

1. Identification
2. Assessment
3
3. Intervention
4
4. Monitoring
5
5. Outcome
Disease Registry — Click a condition to view patient list
Condition ICD Category Enrolled Active in Program Avg Compliance % Outcomes Met % Trend
Type 2 Diabetes (T2DM)E11.x23419874%68%▲ +4%
Congestive Heart Failure (CHF)I50.x897281%75%▲ +2%
COPDJ44.x675966%61%▼ -1%
HypertensionI10.x31228782%79%▲ +6%
CKD Stage 3+N18.3–N18.614511871%64%▲ +3%
Patients — Type 2 Diabetes (T2DM)
234 enrolled
MG
Maria Gonzalez
HbA1c: 8.1% · Last contact: Mar 22
Review
JT
James Thompson
HbA1c: 7.2% · Last contact: Mar 28
On Track
SP
Sunita Patel
HbA1c: 9.4% · Last contact: Feb 14
High Risk
RW
Robert Williams
HbA1c: 7.8% · Last contact: Mar 15
On Track
JK
Janet Kim
HbA1c: 10.2% · Last contact: Jan 30
Overdue
EO
Emeka Okonkwo
HbA1c: 7.5% · Last contact: Mar 27
On Track
CR
Carlos Rodriguez
HbA1c: 8.7% · Last contact: Mar 10
Review
Active Interventions — T2DM Program
147
Education Sessions
98
Med Management
62
Specialist Referrals
84
Lifestyle Coaching
T2DM Program Summary
Avg HbA1c reduction (enrolled)-1.2%
ER visits (program vs non-enrolled)-34%
30-day readmission rate8.2%
Medication adherence (PDC)82%
Annual eye exam completion71%
Foot exam completion64%
Page Guide — Chronic Disease Management
Overview
Chronic Disease Management (CDM) programs help members with high-burden conditions achieve better health outcomes through structured care plans, regular monitoring, and proactive interventions.
  • Click any condition row to view the enrolled patient list
  • Workflow stages show where the current cohort is in the program cycle
  • Interventions are tracked at the individual patient level
Disease Registry
The registry is populated from claims data, lab results, and clinical documentation. Enrollment is semi-automated using ICD-10 code clusters. Compliance % measures patient adherence to program touchpoints. Outcomes Met % measures achievement of clinical targets (e.g., HbA1c <8%).
Intervention Types
  • Education: Group or individual sessions covering disease self-management
  • Medication Management: Reconciliation, adherence monitoring, refill support
  • Specialist Referral: Coordinated referrals with closed-loop follow-up
  • Lifestyle Coaching: Nutrition, exercise, and behavioral health support
Patient Status Badges
  • On Track Meeting clinical targets
  • Review Borderline targets, needs attention
  • High Risk Deteriorating metrics, escalate care
  • Overdue No contact in >30 days, outreach needed