As part of our chronic condition management program, we send mailings to potential participants and providers as outlined in the Opportunities for Care table below. Many of these outreach opportunities come as a result of the assessments that we perform and our approach to addressing potential gaps in care.

Regardless of identified gaps in care, you will receive a letter letting you know that your patient initiated chronic condition management coaching. You will receive the letter within 45 days of the first coaching session.

Depression screenings

Screening for depression is a routine component of our chronic condition management program. We encourage the identification and treatment of behavioral health disorders that may co-exist with medical conditions. Coaches provide telephonic or secure fax outreach to providers for PHQ9 or GAD7 screenings that score ≥ 15. This outreach occurs within 3-5 business days or within 1 business day, if urgent.

Gaps in care

We identify evidence-based gaps, omissions, and errors in care, and communicate these possible gaps to providers and participants in writing, within 5-15 business days from identification. The integration of potential gaps in care within our chronic condition management program results in a coordinated outreach to customers and their providers, which helps improve clinical outcomes, increase medical cost savings, and raise productivity.

Treatment Barriers

Our goal is to guide and support customers as they work to improve their health behaviors and advocate for their health care goals in conjunction with evidence-based medical treatments. Occasionally, barriers prevent customers from achieving their goals or communicating concerns to their provider. Telephonic or secure fax communication by our coaches occurs when identified barriers to treatment and abnormal biometrics are present. The coach may outreach to the provider one to three business days from their last contact with the patient, providing medical/behavioral information.

Safety & Urgent Care

A medical or behavioral clinician triages all potentially urgent situations and telephonic communication will be done by our coach with in one business day, if our assessment determines a safety or urgent situation.

Opportunities for Care

Chronic Condition	Identified Gap and Opportunity for Care
Asthma (Pediatric)	Medication adherence Compliance with medication types and categories
Asthma (Adult)	Combination drug therapy Compliance with medication types and categories Emergency room utilization triggers Medication adherence
Chronic obstructive pulmonary disease (COPD)	Compliance with medication types and categories Medication adherence
Coronary artery disease (CAD)	Compliance with medication types and categories Medication adherence Office visit follow-up
Congestive heart failure (CHF)	Compliance with medication types and categories Medication adherence Medication contraindication alerts Medication indication alert
Depression	Compliance with medication types and categories Medication adherence
Diabetes	Compliance with medication types and categories Lab screenings validation Medication adherence Medication indication alerts