Chronic Care Coordination


“Rising risk” patients are three times more likely to be admitted to the hospital than the average patient. If you’re not coordinating care for your rising risk population, you may be missing out on a major opportunity to reduce costs and improve patient outcomes. The Healthy Every Day Chronic Care Coordination program can help.

Who qualifies as rising risk?

  • Patients who have one or more chronic condition but aren’t sick enough to qualify for traditional care management programs (generally, 25-35% of a Medicare population)

The Chronic Care Coordination program is ideal for managing patients with:

  • Heart Failure
  • COPD
  • Diabetes
  • General frailty, age related issues

Care Coordination Program Features

  • Daily health survey accessible by phone or Internet connection
  • Survey questions tailored to assess the clinical status, self-care activities and social determinants of health
  • Care coordination worklists and alerts through the Navitas platform

Care Coordination Program Outcomes

Approximately 40% reduction in all type admissions for enrolled patients

Sara AldworthChronic Care Coordination