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Transform chronic care

A new, community-based approach to condition management


Sree Chaguturu, MD, Executive Vice President & Chief Medical Officer


Based on plan member needs and the evolving health care delivery landscape, we believe that a new transformative approach is needed to help people with chronic conditions. The COVID-19 pandemic has re-emphasized the urgency of this need. By helping improve an individual’s overall risk profile, we can help that person become less vulnerable.

Given our health care expertise, along with investments in analytics and infrastructure, CVS Health has a unique opportunity to make transformative changes in care management and delivery. We have deployed these assets to develop a new approach to the management of chronic conditions. Our model moves far beyond existing disease management programs, as it is based in, and utilizes, our community presence across the country.

Our new approach is member-centric and highly personalized. It’s enabled by the work of thousands of associates, data scientists, analysts and clinicians behind the scenes to develop, build and implement Transform Chronic Care. Their work provides the foundation our pharmacists and health care practitioners are using every day to serve members and help them on their path to better health.


Individualized Care Experience

  • The member experience:
  • Enabled by:
    • Holistic, real-time member data view
    • Advanced analytics to determine member-specific next best actions
    • Prioritized, member-specific health profile
    • Individualized communication plan


The key to our approach to chronic care is an individualized care plan based on member-specific data. Depending on the program, our holistic member view includes pharmacy and medical claims, lab results, demographic data, and engagement history. Our analytics engine sorts and organizes the data to develop a personalized profile and care plan for individual members. The care plan identifies the most likely-to-be-effective “next best” step needed to improve health and close gaps in care. The member view is continuously updated with each intervention, enabling coordination of messaging through all channels.


One-on-One Engagement

  • The member experience:
  • Enabled by:
    • Special training for pharmacists
    • Optimized pharmacy workflow
    • Comprehensive member view with prioritized next best actions
    • Register prompts for in-store counseling
    • EHR connectivity
    • CRM tools to ensure continuity
    • Best-in-class documentation to support ongoing relationshipolistic, real-time member data view


One of the most effective ways to translate the individualized care plans into action is through one-on-one engagement, either telephonically or face-to-face in our pharmacies. Members identified as having a high potential for adverse events or complications in our chronic care programs are assigned to Pharmacist Panels for proactive outreach and counseling from specially trained pharmacists.

To help ensure Panel pharmacists have sufficient time to engage members, we’ve optimized workflows, prioritizing their time for counseling. We use analytics to adjust staffing and scheduling to meet anticipated volumes in a particular store over the course of the day and the week.

Member data is reviewed on a regular basis for open opportunities — any of more than 50 unique interventions. The system prompts telephonic outreach and can anticipate when a Pharmacist Panel member may be visiting the store to pick up a refill. In either case, the pharmacist reviews the member’s open opportunities and their interaction history in advance to prepare to address that individual’s next best action.

A best-in-class documentation system and integrated use of customer relationship management (CRM) tools help ensure that the pharmacist is fully informed on past interactions with every counseling session. Electronic health record (EHR) connectivity to providers ensures continuity of care.


Local Care Delivery

  • The member experience:
  • Enabled by:
    • 1,500 CVS HealthHUB locations by 2021
    • Expanded in-store team of clinical professionals
    • Private consultation rooms
    • Expanded wellness offerings, wellness room
    • EHR connectivity with member’s care team


Nine out of 10 people with a chronic condition feel they need more help.1 CVS Health is making help available right in the neighborhood — convenience that counts, particularly when a visit to a physician’s office or hospital may be challenging. With a comprehensive view of the data and in-depth engagement, our pharmacists can identify gaps in care and educate members about opportunities for follow-up with in-store MinuteClinic clinicians.

Our rapidly growing network of HealthHUB stores offers an expanded team of clinical professionals, including nurse practitioners and licensed practical and vocational nurses. Pharmacists provide critical support, operating at the top of their license. Private consultation rooms enable in-depth conversations that can help uncover the obstacles that may keep a member from effectively managing their health issues. Care Concierges provide face-to-face support to help members navigate health services and resources. HealthHUB services include foot and eye exams for members with diabetes, sleep assessments and solutions, weight management, and a range of other screening services.

Because lifestyle is a critical factor in managing most chronic conditions, HealthHUB locations also offer expanded wellness and educational services, and include a designated wellness room which can be used for group activities, such as condition education or yoga training.


Helping Members Manage Chronic Conditions

To better support members with chronic conditions we have enhanced and updated existing programs, and are introducing new ones, all offering a personalized care experience, one-on-one engagement, and local care delivery.

  • Our core adherence program, Pharmacy Advisor, now uses advanced analytics to identify members with a high likelihood of non-adherence and to generate deeper, more individualized insights about how to help. It offers proactive outreach to members with any of ten chronic conditions.
  • Our new Health Advisor program incorporates medical and lab data with pharmacy data to individualize counseling and help close gaps in care for more than 100 chronic conditions.
  • Next generation Transform Diabetes Care uses comprehensive member data to prioritize diabetes-specific recommendations shared through pharmacist and care team counseling as well as telephonic coaching. Pharmacists can inform members about the availability of needed services at their local MinuteClinic and/or CVS HealthHUB locations.

CVS Health uses and shares data as allowed by applicable law, and by our agreements and our information firewall.

This page contains trademarks or registered trademarks of CVS Pharmacy, Inc. and/or one of its affiliates.

Image source: Licensed from Getty Images, 2020.