Chronic Disease Management

Powerful Analytics, Years of Experience

AHDI has been successfully managing chronic conditions for employers for well over a decade. We identify chronic conditions in a population through medical benefit claims or self-identification utilizing a Health Risk Assessment.

Our Healthcare Navigator™ Nurses are trained in Motivational Interviewing to coach those identified with any of the 27 conditions that we track.

Our goal is long-term behavioral change to improve patient self-management. The program will reduce claims costs depending on the prevalence of chronic disease in a population and the employer’s support for program participation.

We have evaluated the financial effectiveness of the program multiple times, and the most recent evaluation has been accepted for publication in a peer-reviewed medical journal. This evaluation indicates a reduction in cost of about 14% compared to what would be expected, given all of the members’ medical conditions. Since these members account for about two-thirds of the total medical claims cost for self-funded plans, the average total expense reduction is about 9%.

Chronic Diseases and Standards of Care

Backed by patented and proven techniques, AHDI has developed a program of minimum recommended care for 27 chronic diseases. These preventative measures have been proven to substantially decrease the risk of serious illness and even death.
(Always check with your doctor before undergoing any medical procedures)

Standards of Care Table

Chronic Condition
Minimum Recommended Annual Care
Asthma
2 Clinical Evaluations
1 Spirometry (for patients 10 years of age or older)
Atherosclerosis (Peripheral Vascular Disease)
1 Clinical Evaluation
1 LDL
Atrial Fibrillation
1 Clinical Evaluation
Chronic Kidney Disease
1 Clinical Evaluation
1 Serum Creatinine
1 Serum Calcium
1 HGB or Hrct
1 Serum Potassium
1 Serum Phosphorus
Chronic Obstructive Pulmonary Disease
1 Clinical Evaluation
1 Spirometry
Chronic Venous Thrombotic Disease
1 Clinical Evaluation
Congestive Heart Failure
1 Clinical Evaluation
1 Serum Creatine
1 Serum Potassium
Coronary Artery Disease
1 Clinical Evaluation
1 LDL
Depression
1 Clinical Evaluation
Diabetes
2 Clinical Evaluations
1 Lipid Panel
2 HcgA1c
1 Serum Creatinine
1 Urine Albumin/Creatinine ratio, Total Protein (if no nephropathy Dx or ACE/ARBRx)
Epilepsy
1 Clinical Evaluation
Human Immunodeficiency Virus Infection (HIV)
2 Clinical Evaluations
2 HIV Quantifications
2 CBC's
1 Pap Smear (for women only, 21 years of age or older
1 T-Cell/Cd-4 Count
Hyperlipidemia
1 Lipid Panel
Hypertension
1 Clinical Evaluation
1 Serum Creatinine
Hyperthyroidism
1 Clinical Evaluation
1 TSH
1 T4
Hypothyroidism
1 Clinical Evaluation
1 TSH
Metabolic Syndrome
1 Clinical Evaluation
1 Lipid Panel
1 FBS or HcgA1c
Multiple Sclerosis
1 Clinical Evaluation
Parkinson's Disease
1 Clinical Evaluation
Polymyalgia Rheumatica
2 Clinical Evaluations
2 ESR or CRP
1 CBC
Pre-Diabetes
1 Clinical Evaluation
1 Lipid Panel
1 FBS or HgbA1c
Pulmonary Hypertension (non-COPD)
2 Clinical Evaluations
Pulmonary Hypertension with COPD
2 Clinical Evaluations
12 months of supplemental O2 Tx
1 Spirometry
Regional Enteritis (Inflammatory Bowel Disease)
1 Clinical Evaluation
Rheumatoid Arthritis
1 Clinical Evaluation
Sleep Apnea
1 Clinical Evaluation
Ulcerative Colitis
1 Clinical Evaluation

Standards of Care by Chronic Disease

Asthma

Asthma is a chronic lung condition causing the lining of the airway to swell (inflammation). Chest muscles tighten causing the airway to narrow limiting the amount of air that can pass through the airway.  Common symptoms are wheezing, coughing, a feeling of chest tightness or other breathing trouble.  Often people complain of feeling out of breath, unable to breathe out, shortness of breath or breathing faster than normal.
Minimum Recommended Annual Care
  • 2 Clinical Evaluations
  • 1 Spirometry (for patients 10 years of age or older)

Atherosclerosis (Peripheral Vascular Disease)

Atherosclerosis is a slow disease where arteries become clogged and hardened. It can lead to heart attack, stroke, and vascular dementia and is found in 80-90% of Americans over the age of 30.

Minimum Recommended Annual Care
  • 1 Clinical Evaluation
  • 1 LDL

Atrial Fibrillation

Atrial fibrillation is a common called A-fib, is a type of abnormal heartbeat where the heart rhythm is fast and most often irregular.

Minimum Recommended Annual Care 
  • 1 Clinical Evaluation

Chronic Kidney Disease (CKD)

Chronic kidney disease is the slow loss of kidney function over time. The main job of the kidneys is to remove wastes and excess water from the body.

Minimum Recommended Annual Care
  • 1 Clinical Evaluation
  • 1 Serum Creatinine
  • 1 Serum Calcium
  • 1 HGB or Hrct
  • 1 Serum Potassium
  • 1 Serum Phosphorus

Chronic Obstructive Pulmonary Disease (COPD)

Chronic obstructive pulmonary disease (COPD) is a condition in which there is reduced airflow in the lungs. The disease develops and worsens over time. COPD is not reversible, but therapy can slow its progress, reduce symptoms, and improve quality of life.
Minimum Recommended Annual Care
  • 1 Clinical Evaluation
  • 1 Spirometry

Chronic Venous Thrombotic Disease

Chronic Venous Thrombotic Disease—also know as deep vein thrombosis (DVT)—is a condition that occurs when a blood clot forms in a vein deep inside a part of the body. DVT mainly affects the large veins in the lower leg and thigh, but can occur in other deep veins, such as in the arms and pelvis. DVT most often affects only one side of the body.
Minimum Recommended Annual Care
  • 1 Clinical Evaluation

Congestive Heart Failure

Heart failure is a condition in which the heart does not pump enough blood to meet the needs of the body’s tissues. It has many causes. Heart failure can develop slowly over time as the result of other conditions (such as high blood pressure and coronary artery disease) that weaken the heart. It can also occur suddenly as the result of damage to the heart muscle or an acute valve problem.
Minimum Recommended Annual Care
  • 1 Clinical Evaluation
  • 1 Serum Creatine
  • 1 Serum Potassium

Coronary Artery Disease

Coronary heart disease is a narrowing of the small blood vessels that supply blood and oxygen to the heart. Coronary heart disease (CHD) is also called coronary artery disease.
Minimum Recommended Annual Care
  • 1 Clinical Evaluation
  • 1 LDL

Depression

Depression is feeling sad, blue, unhappy, or down in the dumps. Most people feel this way once in a while.
Minimum Recommended Annual Care
  • 1 Clinical Evaluation

Diabetes

There are two major forms of diabetes: Type 1, previously called insulin-dependent diabetes mellitus (IDDM) or juvenile-onset diabetes; and type 2, previously called non-insulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes. There are other forms of diabetes that account for about 1 out of every 20 people with diabetes.
Minimum Recommended Annual Care
  • 2 Clinical Evaluations
  • 1 Lipid Panel
  • 2 HcgA1c
  • 1 Serum Creatinine
  • 1 Urine Albumin/Creatinine ratio, Total Protein (if no nephropathy Dx or ACE/ARBRx)

Epilepsy

Epilepsy is a brain disorder in which a person has repeated seizures over time. Seizures are episodes of uncontrolled and abnormal firing of brain cells that may cause changes in attention or behavior. This condition is also called a seizure disorder.
Minimum Recommended Annual Care
  • 1 Clinical Evaluation

Human Immunodeficiency Virus Infection (HIV)

Human immunodeficiency virus (HIV) is the virus that causes AIDS. When a person becomes infected with HIV, the virus attacks and weakens the immune system.
Minimum Recommended Annual Care
  • 2 Clinical Evaluations
  • 2 HIV Quantifications
  • 2 CBC’s
  • 1 Pap Smear (for women only, 21 years of age or older
  • 1 T-Cell/Cd-4 Count

Hyperlipidemia

Cholesterol is a fat (also called a lipid) that your body needs to work properly. Too much bad cholesterol can increase your chance of getting heart disease, stroke, and other problems—one of which is hyperlipidemia.
Minimum Recommended Annual Care
  • 1 Lipid Panel

Hypertension

Blood pressure is a measurement of the force exerted against the walls of your arteries as your heart pumps blood to your body. Hypertension is the term used to describe high blood pressure (HBP).
Minimum Recommended Annual Care
  • 1 Clinical Evaluation
  • 1 Serum Creatinine

Hyperthyroidism

Hyperthyroidism is a condition in which the thyroid gland makes too much thyroid hormone. The condition is often called overactive thyroid.
Minimum Recommended Annual Care
  • 1 Clinical Evaluation
  • 1 TSH
  • 1 T4

Hypothyroidism

Hypothyroidism is a condition in which the thyroid gland does not make enough thyroid hormone. This condition is often called underactive thyroid.
Minimum Recommended Annual Care
  • 1 Clinical Evaluation
  • 1 TSH

Metabolic Syndrome

Metabolic syndrome is a name for a group of risk factors that occur together and increase the chance of having coronary artery disease, stroke, and type 2 diabetes.
Minimum Recommended Annual Care
  • 1 Clinical Evaluation
  • 1 Lipid Panel
  • 1 FBS or HcgA1c

Multiple Sclerosis

Multiple sclerosis (MS) is an autoimmune disease that affects the brain and spinal cord (central nervous system). It can also be called MS or Demyelinating disease.
Minimum Recommended Annual Care
  • 1 Clinical Evaluation

Parkinson's Disease

Parkinson’s disease results from certain brain cells dying. These cells help control movement and coordination. The disease leads to shaking (tremors) and trouble walking and moving.
Minimum Recommended Annual Care
  • 1 Clinical Evaluation

Polymyalgia Rheumatica

Polymyalgia rheumatica (PMR) is an inflammatory disorder. It involves pain and stiffness in the shoulders and often the hips.
Minimum Recommended Annual Care
  • 2 Clinical Evaluations
  • 2 ESR or CRP
  • 1 CBC

Pre-Diabetes

Pre-diabetes occurs in those individuals with blood glucose levels that are higher than normal but not high enough for a diabetes diagnosis.
Minimum Recommended Annual Care
  • 1 Clinical Evaluation
  • 1 Lipid Panel
  • 1 FBS or HgbA1c

Pulmonary Hypertension (non-COPD)

Pulmonary hypertension is high blood pressure in the arteries of the lungs. It makes the right side of the heart work harder than normal.
Minimum Recommended Annual Care
  • 2 Clinical Evaluations

Pulmonary Hypertension with COPD

Pulmonary hypertension is most commonly associated with chronic obstructive lung disease (COPD) but may also be associated with some types of heart disease, auto-immune diseases, and other, rarer, conditions.
Minimum Recommended Annual Care
  • 2 Clinical Evaluations
  • 12 months of supplemental O2 Tx
  • 1 Spirometry (for patients 10 years of age or older)

Regional Enteritis (Inflammatory Bowel Disease)

Regional Enteritis (Inflammatory Bowel Disease) is a disease where parts of the digestive tract become inflamed. It most often involves the lower end of the small intestine and the beginning of the large intestine.

Minimum Recommended Annual Care
  • 1 Clinical Evaluation

Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a disease that leads to inflammation of the joints and surrounding tissues. It is a long-term disease. It can also affect other organs.
Minimum Recommended Annual Care
  • 1 Clinical Evaluation

Sleep Apnea

People with sleep apnea stop breathing for short periods of time while they are asleep. They usually do not wake up completely when this happens, but in the morning, they feel exhausted and continue to feel sleepy during the day.
Minimum Recommended Annual Care
  • 1 Clinical Evaluation

Ulcerative Colitis

Ulcerative colitis is a condition in which the lining of the large intestine (colon) and rectum become inflamed. It is a form of inflammatory bowel disease (IBD). Crohn disease is a related condition.
Minimum Recommended Annual Care
  • 1 Clinical Evaluation