Chronic Care Management
Identifying Individuals Who Benefit from Targeted Chronic Care Management Interventions
Chronic diseases are complex problems that lead to higher mortality, utilization of services and a greater cost. According to the CDC, 6 in 10 adults have a chronic disease and 4 in 10 have two or more.1 Caring for these individuals can be as complex as their medical conditions leading to avoidable utilization, admissions and lost engagement opportunities. With the Jvion CORE™, customers can use clinical AI to understand who the patients are that can realize a different outcome while also reducing readmissions and unnecessary utilization. The CORE also provides guidance on the best channel and time for communications as providers and payers look to increase engagement and effective self-management.
Jvion’s CORE integrates clinical and socioeconomic data to:
- Predict utilization independent of the patient’s clinical condition
- Surface the social determinants of health that confer the greatest risk
- Pinpoint the risk factors that if addressed will optimize care management effectiveness
- Identify and manage avoidable costs tied to readmissions and ED utilization
Please use the form on this page to request more information about these purpose-built solutions for Chronic Care Management:
- Avoidable Admission: 30/60/90 Days
- Avoidable ED Visit: All-Cause
- Avoidable Admission: Diabetes
- Avoidable ED Visit: CHF
- ED High Utilizers
1. https://www.cdc.gov/chronicdisease/resources/infographic/chronic-diseases.htm
Featured Product
CHF Utilization
The total annual cost of preventable CHF hospitalizations in the US is over $8,381 million.2 Research has shown, however, that access to quality outpatient care and disease management programs improves disease treatment and outcomes. Given the substantial healthcare and mortality burden of CHF, it is imperative there are continued improvements in CHF prevention, management and surveillance.
Jvion goes beyond traditional predictive analytics that simply stratifies patients based on obvious risks. The Jvion CORE identifies patients on a trajectory to become high utilizers because of CHF while there is still time to intervene. Clinicians, case managers, and care coordinates are given personalized and prioritized recommendations for each patient based on their clinical, socioeconomic and behavioral risk factors. As the recommendations are implemented and documented, the patient’s trajectory towards an admission, ED visit or high cost care event is adjusted towards a more positive outcome.
2. Jiang HJ, Russo CA, Barrett ML. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet] Agency for Health Care Policy and Research (US); Rockville (MD): [Accessed January 7, 2014]. 2009. Nationwide Frequency and Costs of Potentially Preventable Hospitalizations, 2006: Statistical Brief #72. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb72.jsp. [Google Scholar] [Ref list]
Who We Help
Providers
Identify patients likely to benefit from intervention before an adverse event
Providers
A lifeline for patients with chronic diseases, providers are instrumental in coordinating care and managing chronic conditions. With the Jvion CORE, providers can identify patients likely to benefit from an intervention before an adverse event and provide an individualized care plan. The result is fewer adverse outcomes, managed costs and saved lives.
Payers
Develop strategies for maintaining member health
Payers
With the population aging, increasing chronic diseases will add to the already substantial financial burden faced by health plans. Jvion CORE can help Payers develop strategies for maintaining the health of their members and improving patient outcomes while reducing costs.
Public Health Agencies
Gain critical insights about your population to improve community health
Public Health Agencies
Public health agencies face a substantial financial burden due to chronic disease. According to the CDC, chronic disease accounts for approximately 75 percent of the nation’s aggregate health care spending – or an estimated $5,300 per person in the US each year. In terms of public insurance, treatment of chronic disease constitutes an even larger proportion of spending – 96 cents per dollar for Medicare and 83 cents per dollar for Medicaid. Jvion CORE can provide these service agencies with critical insights about their populations and the effective deployment of resources to address preventable problems and improve overall community health.
PBM
Positively impact care through medication adherence strategies
PBM
Medication adherence is extremely important to managing and improving the health and lives of individuals with chronic conditions. Many people do not comply with their medication regime because of lack of knowledge or understanding. The Jvion CORE can identify the patients at highest risk for developing a complication as a result of medication non-compliance related to their chronic condition and map out personalized recommendations and the best way to communicate those to change a potential adverse outcome.
Partners
Integrate prescriptive AI into existing platforms to improve chronic care management
Partners
Integrate clinical AI insights from Jvion CORE into existing patient facing portals, population health platforms, EHRs and other systems that aim at improving the management of chronic conditions.
Patient Impact Story
Care Manager Intervention Helps Patient Avoid Hospital Admission
45-year-old male nurse who works the night shift and is currently diagnosed with hypertension, high cholesterol, and type 2 diabetes was identified by the Jvion CORE as high-risk for health regression. The care coordinator actioned Jvion’s recommendations by providing education and guidance on mealtimes, exercises and taking medications given a non-traditional work schedule. In addition, the care coordinator was able to connect the employee to a hospital-led diabetes support group and assistance with supplies needed to manage his diabetes.
Since the recommendations, the employee has maintained his HbA1c <7% and has not had an admission or an ED visit within the past 6 months.