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


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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. [Google Scholar] [Ref list]

Who We Help

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.

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  • (972) 831-7270 | 222 W Las Colinas Blvd., Suite 2200N Irving, TX 75039
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  • Download the latest SmartFocus paper “The COVID Aftermath: Why behavioral health is the next crisis health plans should be prepared to manage” brought to you by Jvion and SmartBrief to understand why the current state of analytics leave members and health plans exposed to a behavioral health crisis.

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