Chronic-care outcomes report
Sample Health Plan · Q3 2026
412 enrolled members · Programme month 6 · Reporting period 1 Jul – 30 Sep 2026
Conditions overlap: 45 members have both hypertension and diabetes. Baseline is each member's first 30 days on the programme.
Programme summary
Active monthly
81%
target over 75%
Retained at 6 months
84%
90% at 3 months
On-time refills
86%
baseline 58%
Avg refill gap
2.1 days
baseline 9.4 days
Alert to contact
5.2 hrs
median, 94% same day
Reviews attended
78%
baseline 61%
Hypertension
268 members · target below 140/90 mmHgBP at target
61%
from 38%
Mean BP
138/86
from 152/94
Weekly readings logged
74%
Urgent readings escalated
17
all contacted within 4 hrs
Diabetes
151 members · 118 with a repeat HbA1c at month 6HbA1c below 7%
44%
from 29%
Mean HbA1c
7.8%
from 8.6%
Glucose readings in range
58%
from 41% (4.4–7.2 mmol/L fasting)
Low-glucose alerts
11
all contacted within 24 hrs
Baseline
Month 6
Dialysis
38 members · 1,368 scheduled sessions this quarter (3 per week)Sessions captured
94%
1,284 of 1,368
Kt/V at target
79%
≥1.2 · mean 1.31
Missed sessions
3.2%
from 6.1%
High fluid gain (over 4%)
14%
of sessions, from 22%
What this quarter shows
• BP control rose steadily each month, with the biggest gains among members whose family Circle funds refills.
• High-risk diabetes (HbA1c above 9%) fell from 30% to 18% of members with repeat tests.
• Nearly every outside dialysis session now reaches a clinician within three days.
How these figures are produced
Home readings from the TunzaCare app, clinic and lab results shared by partner hospitals, and refill records from partner pharmacies. Members consented to aggregated reporting. No individual is identifiable. Targets follow the treating clinicians' protocols.