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CORE Population Health Management

ANDNEXT FOR DIABETES AND HYPERTENSION

Greater control of diabetes and hypertension through in-home care that addresses barriers to better health.

AndNext
One achievable step toward lasting stability.

Traditional office-based care doesn't always reveal the barriers that keep members from making progress. With AndNext, our Nurse Practitioners and Care Coordinators meet members in their homes to understand each member’s health, medications, goals, and day-to-day challenges.

Our team develops a plan alongside the member that connects clinical care with support for those barriers, identifies achievable next steps, and adjusts as needs change. We stay connected virtually between visits to monitor progress, make changes, and celebrate progress. 

Our goal is to help members move toward sustained control of diabetes and hypertension, to have greater confidence in self-management, and to successfully transition graduates to community providers to maintain their progress.

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  • Improved control of diabetes and hypertension

  • More confidence in self-management

  • Reduced barriers to better health

  • Warm transition to community providers

This approach reflects evidence that social and economic conditions influence diabetes self-management and outcomes.¹ It is also consistent with randomized trial evidence showing that structured community-based support, telehealth coaching, and ongoing clinician feedback can improve blood sugar control among low-income adults with type 2 diabetes.²

1. Hill-Briggs F, et al. Diabetes Care. 2021;44:258–279.

2. Vaughan EM, et al. JAMA Intern Med. 2026;186:1012–1021.

Key Features

In-person visits by Nurse Practitioners and Care Coordinators

Personalized care plans centered around achievable steps to greater control.

Value-based contract with shared risk and savings

In-home testing with telemonitoring for HbA1c and blood pressure 

Addresses individual social needs and barriers to improvement

Warm transition to community providers upon graduation

Medication support, education, and additional telemedicine visits as needed

Access to live non-emergency help, direct from CHP, every day of the year 

Member connectivity technology

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RESPECT • TRUST • CARE

At Catalytic Health Partners we take social and behavioral needs beyond the “basics” to ensure stability so that medical needs can be achieved.

 

Catalytic Health Partners includes mental health services and clinical encounters by credentialed providers to support MLR.

Michelle L, Member

“The CHP team opened doors for me that were closed before so I could get the care I needed.”
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