Enhanced Care Pilot — Clinical Outcomes

A government health financing pilot was tracking a comorbid population across multiple clinics with no systematic way to measure quarterly outcomes. Conditions included diabetes, CVD, and hypertension. Data collection was fragmented, and reporting was anecdotal. Leadership needed to know if the program was working, and clinical staff needed to see where patients were falling through the cracks.

Mapped existing data-collection workflows, then redesigned inputs for the second enrollment round. Structured datasets for A1C, blood pressure, BMI, foot exams, and asthma action plans. Built interpretive charts, trend analyses, and a BMI/blood-pressure scattergraph using Excel, R, and Python, all designed for non-technical decision-makers. Phased deployment over two years allowed iterative refinement.

Replaced storytelling with auditable metrics: 88.5% A1C success rate, 84.9% BMI success rate, 60.6% blood-pressure success rate. The reports clearly showed where the program met its mandate and where it fell short, giving clinical staff and executives a shared, data-driven foundation for ongoing care design.