How Technology is Closing Care Gaps in Managing Chronic Conditions

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Key Takeaways

• Patients with chronic conditions move between inpatient, outpatient and community settings, often carrying overlapping risks that lead to readmissions, complications and even preventable deaths.
• By combining acute and ambulatory electronic health record (EHR) data, benchmarks and social determinants of health, Premier's Quality Continuum solution tracks patients across the full continuum of care and equips providers with a tool designed to identify high-risk patients sooner, improve care coordination and prevent avoidable complications readmissions and mortalities with a first in industry cross continuum risk score.
• Early adopters are already seeing value: St. Luke's University Health Network is using the Quality Continuum Diabetes Dashboard to better compare practice performance and streamline care management, while Avera Health is enhancing capabilities that highlight maternal health risks not captured in existing registries.

For decades, healthcare providers have measured quality largely within the walls of the hospital. But as the industry continues to shift toward value-based care, one reality is becoming clear: the need to drive quality doesn't stop at discharge. Patients with chronic conditions move between inpatient, outpatient and community settings, often carrying overlapping risks that lead to readmissions, complications and even preventable deaths.

And too often, leaders have had to rely on retrospective, claims-based reports or siloed electronic health record (EHR) registries that don't tell the full story. That's the gap Premier's new Quality Continuum solution is designed to close.

Introducing Quality Continuum

Built as an extension of Premier's Quality Enterprise, Quality Continuum goes further than traditional dashboards by combining acute and ambulatory EHR data, national benchmarks and social determinants of health (SDOH) into one place. This comprehensive view enables health systems to actively measure outcomes and potentially improve them.

One key condition in focus is diabetes, which effects nearly one-third of hospitalized patients in the U.S. The dashboard highlights measures such as HbA1c and blood pressure control, comorbidities like kidney disease and cardiovascular conditions and whether patients are receiving timely follow up care after discharge.

Future modules are planned for expansion into maternal health, cardiac, pulmonary and oncology care- all areas where proactive management have the potential to dramatically improve outcomes.

This approach also aligns with the Centers for Medicare & Medicaid Services (CMS) Innovation Center's 2025 strategy, which emphasizes earlier detection, stronger prevention and better management of chronic disease. By moving beyond retrospective billing data, Quality Continuum helps health systems stay ahead of regulatory requirements and gives them a tool designed for their efforts to keep patients healthier.

Driving Smarter Care Decisions

At its core, Quality Continuum empowers leaders at multiple levels of care delivery:

• Primary care and medical group executives gain visibility into provider and practice comparisons, identifying top performers and opportunities for improvement.
• Care management teams receive patient-level risk stratification and actionable data that highlights social and clinical vulnerabilities, allowing them to target outreach more efficiently.
• Quality and population health leaders can validate the effectiveness of interventions, track readmission risk and share best practices system-wide.

Real-World Impact

St. Luke's University Health Network Brings Ambulatory Data into Focus

For years, St. Luke's University Health Network in Pennsylvania relied on robust inpatient benchmarks to drive improvement. However, the health system lacked the same visibility into its ambulatory population.

"About 10 years ago, we joined a Medicare Shared Savings Program (MSSP) and formed a value-based care committee," said Donna Sabol, Chief Quality Officer at St. Luke's. "But we quickly realized it was too late to get our Merit-based Incentive Payment System (MIPS) or MSSP data when it was already months old. We needed a way to see patient data and outcomes in real time."

St. Luke's became an early adopter of Quality Continuum, piloting the diabetes dashboard. By surfacing timely data on lab values, comorbidities, emergency department (ED) visits and primary care follow-up, the solution has helped St. Luke's identify its most vulnerable patients and compare performance across physician practices.

"We have always developed healthy competition internally," said Sabol. "Now we will have benchmarks from others, and nothing moves the needle faster than being able to compare yourself to peers."

For care managers, the biggest shift has been efficiency. Instead of mining through registries and EHRs, they can quickly drill down to patient-level risk factors and target outreach. "This is going to give our primary care executive team great information to help motivate and incentivize practices to enhance performance," said Sabol.

Expanding to Maternal Health with Avera Health

While diabetes is the first chronic condition available in Quality Continuum, the solution is already being built to address additional areas. Early development partners like Avera Health are helping shape what those future dashboards will look like.

Dr. Kimberlee McKay, an OB-GYN and Medical Officer at the Avera Research Institute, has worked with Premier to apply Quality Continuum to maternal health. Her team serves patients across 33 hospitals and 300 clinics in South Dakota, many of whom face long travel distances for medical care and multiple chronic conditions.

By utilizing Quality Continuum's maternal health capabilities, Avera identified high-risk prenatal patients who weren't showing up on existing care management follow-up lists - including women with mental health conditions, obesity, advanced maternal age and a history of preeclampsia.

"The key to maternal health is managing the chronic disease burden within the pregnancy," said McKay. "You can't just look at your health system in isolation. You must really understand national benchmarks and peer performance. Quality Continuum helps us do that."

For Avera, the maternal health pilot is giving care teams a clearer view of risk factors across the continuum. It is identifying the prenatal patients earlier, so interventions occur before labor and delivery.

The Road Forward

Quality in healthcare has often been measured after the fact. With Quality Continuum, providers can move from retrospective reports to real-time insights that follow patients wherever they receive care. The goal is simple but powerful: give health systems the tools to identify risks earlier, intervene sooner and create lasting improvements in patient outcomes.

For more:

• Ready to see how real-time insights can transform care for your most vulnerable patients? Connect with Premier today.