Chronic Disease Prevention and Control

Program Overview

Managing chronic diseases (including asthma, heart disease, and diabetes) places an overwhelming burden on our region’s health system. Through the Medicaid Transformation’s integrated health system improvement and whole-person approach to care, providers have a unique opportunity to prevent chronic disease, support patient self-management, and reduce costly, preventable complications. This project brings together MCOs, providers, and community resources to ensure all entities are positioned for value-based purchasing after the Medicaid Transformation ends in 2021.

Top Metrics for Improvement

Metrics for this project are currently in draft form and are being updated by the Health Care Authority. The metrics under consideration include:

  • # of health care providers trained in appropriate blood pressure assessment practices
  • # of new / expanded nationally recognized self-management support programs (e.g., CDSMP, NDPP)
  • # of partners participating / implementing each selected model / approach
  • # of partners trained on selected model / approach: projected vs actual and cumulative
  • # of home visits for asthma services, hypertension
  • % of documented, up-to-date Asthma Action Plans
  • % of patients provided with automated blood pressure monitoring equipment
  • Child and Adolescents’ Access to Primary Care Practitioners
  • Comprehensive Diabetes Care: HbA1c Testing
  • Comprehensive Diabetes Care: Medical attention for nephropathy
  • Outpatient Emergency Department Visits per 1000 Member Months
  • Medication Management for People with Asthma (5 – 64 Years)
  • Statin Therapy for Patients with Cardiovascular Disease (Prescribed)
  • Comprehensive Diabetes Care: Eye Exam (retinal) performed


Implemented or expanded use of evidence-based models such as the Chronic Care Model. Informed, supported, and activated consumers, clinicians, and communities. Prepared and proactive health care system, placing more emphasis on prevention to avoid costly treatment.
Reduce number of risk factors, incidence, and relevance of chronic disease decrease, increased access to preventive health services, reduce health disparities, reduce health cost while increasing access to care.
• Raise awareness of chronic disease prevention through community outreach and education
• Educate doctors and nurses on chronic disease prevention and treatment
• Increase frequency of preventative screenings for common chronic diseases
• Expand community paramedicine resources (EMS)
• Improve coordination between medial and community resources for high-risk patients

Evidence-Based Approach

The Chronic Care Model is an organizational approach for caring for people with a chronic disease in the primary care setting. The system creates practical, supportive, evidence-based interactions between an informed, activated patient and a prepared, proactive health care team. The Chronic Care Model supports the overall goal of transitioning to value-based purchasing by reducing the number of admissions and readmissions, improving patient self-management, and controlling costs.

Community paramedicine is an emerging model of community-based health care in which paramedics and EMTs operate in expanded roles to provide routine health care services to underserved populations. Perhaps the best demonstrated benefit of CP programs has been in getting persons who accessed the EMS system, but do not have a medically emergent condition, to more appropriate destinations than a hospital ED. This may yield financial savings and, in some cases, improve the coordination and continuity of care.


You might be interested in the Chronic Disease Prevention and Control project if you see patients with chronic diseases such as asthma, heart disease, and diabetes and want to reduce chronic disease through education and early screenings. The Transformation can expand prevention, self-management services, and annual screenings already in place or create new services to bridge the gap.

Transformation Timeline and Milestones

Project Work Group is working on:

1. Current state assessment
2. Identify Domain 1 strategies that support project
3. Finalize target populations and evidence-based approaches
4. Determine partnering providers
5. Complete implementation plans
6. Plan describing regional transition to fully-integrated managed care

Project Implementation in 2019, and scaling-up in 2020.

Social Determinants of Health and Chronic Disease

A healthy lifestyle is critical to the prevention and treatment of chronic disease, and it’s a lot harder to be healthy if you don’t have a job or a home or enough food. CPAA is committed to working with health care providers and other community-based social services to address health inequities like stable housing, healthy food, health literacy, and reliable transportation to appointments.
This project includes increasing healthy lifestyle habits, regular check-ups with the doctor, preventative screenings, and educational and supportive classes.

Project Area Contact

For more information, contact Kwabana Amoah-Fortson at