Skip to main content

Chronic Disease Prevention and Management

Comagine Health works to improve chronic disease management among Medicare beneficiaries by focusing on communities. Understanding the context of where and how people live and working collaboratively with those who share our objectives is paramount to creating positive and lasting change to the health care system.

Through the Partnership to Reimagine Health Care, we support communities by facilitating collaboration to improve health care outcomes and promote health equity for the beneficiaries that they serve. Chronic disease management can prevent and decrease the impact of many serious conditions common in the population of people over 65. 

Our work aims to address chronic disease by:

  • Increasing hypertension diagnoses and decreasing overall hypertension rates
  • Decreasing diabetes diagnoses
  • Increasing the number of people in cardiac rehabilitation who have experienced a past cardiac event
  • Promoting screening, diagnosis and management of chronic kidney disease (CKD)

Continue reading for more information on the chronic conditions we focus on. You will find a variety of resources corresponding to each condition. We encourage you to reach out to us so we can partner together and make meaningful change to our health care system.


Individuals with hypertension are at greater risk for developing heart disease and stroke and often have other chronic conditions such as diabetes. In the U.S., hypertension is more prevalent in adults aged 65 and older when compared to other age groups. Comagine Health is committed to improving hypertension outcomes for Medicare beneficiaries in our six-state region.

Since hypertension typically does not present with any signs and symptoms and managing it may require incorporating lifestyle changes and medications, patients may be unsure how to best manage their hypertension at home. Comagine Health can partner with you to provide evidenced-based strategies and tools for connecting your patients to community-based and self-measured blood pressure resources to successfully manage their hypertension. 

We offer a variety of services and resources including: 

  • Off-the-shelf and evidence-based resources 
  • Technical assistance (e.g., quality improvement initiatives, pilots, workflow redesign) 
  • Educational events (e.g., webinars) 


With more than a quarter of older adults (65+) in the U.S. living with diabetes, Comagine Health is committed to improving diabetes outcomes and the lives of our Medicare patients in our six-state region — Idaho, Nevada, New Mexico, Oregon, Utah and Washington. 

Identifying and engaging with patients that have diabetes is more important than ever due to the care gaps created by the COVID-19 pandemic. Comagine Health can partner with you to provide evidenced-based strategies and tools for identifying and reengaging patients that have not been seen in the past one year and/or have poor glycemic control, defined as a hemoglobin A1C > 9.0%. 

We offer a variety of services and resources to ensure your success in improving diabetes outcomes in your clinic and community, including:

  • Off-the-shelf and evidence-based resources
  • Technical assistance (e.g., quality improvement initiatives, pilots, workflow redesign)
  • Educational events (e.g., webinars)

Cardiac Rehabilitation

Each year over one million older Americans have a coronary event or undergo a cardiac-related procedure that qualifies them for cardiac rehabilitation (CR).  According to the National Institutes of Health's Institute on Aging, heart attacks, strokes and coronary heart disease are much more likely to develop in people aged 65 and older than in younger populations. 

Research shows that CR can improve  health outcomes and lower health care costs. Benefits include reduced risk of death, fewer symptoms, increased quality of life and decreased risk of heart attack recurrence. Benefits to health systems and communities include reduced readmissions and shortened return-to-work time. Comagine Health is working increase enrollment in CR programs for all patients who have experienced a qualifying cardiac event across our six-state region. 

Below are additional resources to help providers support Medicare beneficiaries in cardiac rehabilitation. 

Chronic Kidney Disease

Chronic kidney disease (CKD) is a public health crisis, disease multiplier, and is often called “the silent killer.” If public awareness of CKD does not increase soon, the total number of patients with kidney failure will likely exceed 1 million by 2030. An estimated 37 million Americans have CKD. 90% of them do not know they have CKD because of low awareness of the importance of CKD testing and diagnosis among practitioners and people at greatest risk. This highlights the need for strategies that improve the frequency of CKD assessment.

Comagine Health is committed to raising awareness and implementing strategies to increase CKD testing and diagnosis for our Medicare beneficiaries including:

  • Promoting testing for CKD with a urine albumin creatine ratio (UACR) and estimated glomerular filtration rate (eGFR) in populations at most risk: patients with diabetes and hypertension.
  • Providing education around risk factor modifications to delay CKD progression and prevent complications is also needed. 
  • Comagine Health offers the following services/assistance when partnering with us:
  • Quality Improvement pilots/workflow processes
  • Evidence-based best practices and resources
  • Webinars and educational events
Chronic Kidney Disease Resources