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Chronic Condition Management

eQHealth Solutions defines Chronic Condition Management as a program designed to target members with specific chronic health conditions. The goal is to improve their health and functional ability by providing condition self-management education, coordinating community resources, addressing all co-morbidities and psychosocial issues that may be affecting the member’s capacity to manage their own health.

Whether the member has one or multiple chronic conditions, is newly diagnosed or has been identified through a formal population health management predictive modeling effort, the Chronic Condition Management Program can provide the additional tools and resources for improved health outcomes. The program focus is holistic management of all the member’s chronic health conditions and psychosocial barriers. 

Core Program Elements:

  • Stabilizing chronic health conditions
  • Producing a clear, practical member plan of care that addresses their healthcare needs and lists specific goals in conjunction with the physician
  • Developing a self-management plan
  • Coordinating multiple care team members ensuring continuity of care
  • Coordinating needed community resources
  • Member empowerment through the use of Motivational Interviewing, Stage of Change Theory and Social Learning Theory

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At-a-Glance: Chronic Condition Management Program Overview

  • Referrals & Member Enrollment: Participants in the program are identified from a variety of sources including physician referrals, a newly diagnosed chronic condition, or predictive modeling, among others.
  • Enrollment Timeframe: Minimum of 2 years.
  • Diagnoses Covered: Chronic health conditions including, but not limited to: asthma, diabetes, heart failure, COPD, depression, chronic kidney disease, HIV/AIDS, dementia/Alzheimer’s, substance abuse, hypertension, coronary artery disease, etc.
  • Mode of Care Coordination: Face-to-face and telephonic services, or telephonic services only.
  • Clinical Quality Measures: HEDIS® and condition specific measures.
  • Outcome Measures: Population health, clinical, and financial measures. Customer satisfaction will be measured for members and providers.

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Why Adopting a Chronic Condition Program is Important for Your Organization?

According to the Center for Disease Control (CDC), about half of all adults—117 million people—have one or more chronic health conditions. And one of four adults has two or more chronic health conditions1. Seven of the top 10 causes of death in 2010 were chronic diseases. Two of these chronic diseases—heart disease and cancer—together accounted for nearly 48% of all deaths3. And, 84% of all health care spending in 2006 was for 50% of the population who have one or more chronic medical conditions2. These are staggering statistics that affect us all.  For organizations, keeping their members’ chronic conditions under control is essential for quality outcomes and financial success.  Adopting a program to address, educate and empower members on managing their conditions will create sustainable behavior change with lasting results.

What Sets eQHealth Solutions' Chronic Condition Solution Apart From the Rest?

Our service offering can be sold as a standalone solution or bundled with our Medical Management comprehensive offering, giving our clients exactly what they need to reach their organizational goals for quality outcomes and cost reductions. Additionally, eQHealth’s Chronic Condition Management service is delivered not only telephonically, but also in person allowing for face-to-face personalized care for your patients/members allowing you to choose the method of care delivery that best suits your needs. Additionally, as part of our solution, you have access to our innovative Population Health Management technology that is second to none in managing your population, clinical, and financial measures.


1Ward BW, Schiller JS, Goodman RA. Multiple chronic conditions among US adults: a 2012 update. Preventing Chronic Disease. 2014;11:130389. DOI:

2Robert Wood Johnson Foundation. Chronic Care: Making the Case for Ongoing Care. Princeton, NJ.

3Centers for Disease Control and Prevention. Death and Mortality. National Center for Health Statistics (NCHS) FastStats Web site.

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