CONDITION MANAGEMENT PHASE 1 CHRONIC DISEASE CHF DIABETES COPD PALLIATIVE ROI REDUCED NUMBER OF: HOSPITALIZATIONS HOSPITAL DAYS ED VISITS RISK MANAGEMENT PHASE 2 HIGH RISK FOR DISEASE OBEISTY SMOKING ROI REDUCED NUMBER OF: MEDICATIONS MISSED WORK DAYS HEALTH MANAGEMENT PHASE 3 RISK PREVENTION SCREEN EARLY DETECTION EDUCATE RISKS ROI REDCUED INCIDENCE OF: ACTIVE DISEASE RISK FACTORS