Good chronic-disease care is proactive and register-driven. commvita finds the people (population segmentation, QOF registers, frailty), closes the gaps (QOF indicators, recall, decision support) and manages the condition (seven condition hubs + a frailty virtual ward) — with a prevention & inequalities lens (CORE20PLUS5) over all of it.
Asthma, chronic obstructive pulmonary disease and bronchiectasis in one hub. Three registers with cross-register analytics in a single place, a pulmonary rehabilitation programme tracker with walk-test and mood scores at both ends, and severity scoring with organism colonisation. Competing systems need separate disease templates and have no rehabilitation tracker at all.This surface is demonstrated on seeded data today; the claim is about how the platform is put together, not about a deployment. From commvita’s own assessment of this module against the systems it competes with. Our assessment, not an independent one.
Live vs demonstrated:Live — real, API-backed platform logic (wired end-to-end today)Demonstrated — representative control surface with seeded data / illustrative UI mock-up
Find → close → manage
Segment the population to find who needs proactive care, surface and close the care gaps, then run the condition on an evidence-based pathway — targeting effort where deprivation makes need greatest.
Find the people
Population health · QOF · frailty
Population Health builds cohorts from free-text (“diabetics with HbA1c > 75 not reviewed in 12 months”) and portable open phenotypes; QOF registers hold the disease populations; Frailty scores CFS 1–9 and runs a virtual frailty ward.
Where in commvita/population-health · API /qof/ · /frailty/.
Close the gaps
QOF · recall · CDSS
QOF tracks 25 indicators across 21 domains with exception reporting and a GPES extract; Recall Management and Repeat Monitoring chase what’s overdue; the CDSS Engine fires NICE/BNF-backed prompts in the consultation.
Where in commvita/qof · /recall-management · API /cdss/.
Manage the condition
Seven condition hubs
Integrated hubs for diabetes, respiratory, heart failure, stroke, cardiac rehab, MSK and neurology — each register-driven, NICE-aligned, with structured reviews and outcome measures. LTC ties multi-condition patients together.
Where in commvita/diabetes-management · /respiratory-hub · /ltc (API /ltc/).
Long-Term Conditions / Dashboardcare_coordinator
☉2 reviews overdue, 1 QOF gap — multi-condition patients surfaced worst-first with the review due and the outstanding indicator.
Build a cohort in plain English or from an open phenotype, preview the count, save it — then push it to recall, social prescribing or a CDSS review. Segmentation becomes action, not a report.
/population-health · Smart Cohortcohort-to-action
2
Close every QOF gap, fairly
QOF registers + exception reporting show exactly who is missing what; recall chases them; the inequality lens (CORE20PLUS5, IMD) targets the effort where deprivation makes the gap widest.
Each condition hub is register-driven and NICE-aligned — e.g. diabetes foot-risk stratification and retinal failsafe, COPD GOLD grading and pulmonary rehab, heart-failure GDMT optimisation — with structured reviews and outcomes.
/diabetes-management/heart-failure · /stroke-care
Where it lives in commvita
Capability
Route
Standard
Status
Population Health (cohorts, phenotypes)
/population-health
API /population-health · openEHR/OMOP
● Live
QOF (25 indicators, exceptions, GPES)
/qof
API /qof/ · QOF
● Live
LTC & reviews (multi-condition)
/ltc · /ltc-reviews
API /ltc/
● Live
Frailty Programme (CFS, virtual ward)
/frailty-programme
API /frailty/ · Rockwood CFS
● Live
CDSS Engine (NICE/BNF prompts)
/cdss
API /cdss/ · NICE · BNF
● Live
Deprivation Mapping (CORE20PLUS5)
/deprivation-mapping
IMD 2019 · CORE20PLUS5
☉ Demonstrated
Diabetes / Respiratory / Heart Failure
/diabetes-management …
NICE NG28 / NG115 / NG106 · QOF
☉ Demonstrated
Stroke / Cardiac rehab / MSK / Neurology
/stroke-care …
SSNAP · BACPR · NICE
☉ Demonstrated
Why this matters. Chronic disease is where most NHS activity and inequality lives. commvita makes it proactive and register-driven — find the cohort, close the QOF gap, run the pathway — and applies a CORE20PLUS5 inequality lens so prevention lands where need is greatest. Non-SaMD: prompts and registers; the clinician acts.
Strategic commissioning & emerging IHOs. Chronic-disease outcomes are what a capitated, outcome-based contract pays for. As ICBs become strategic commissioners and Integrated Health Organisations (IHOs) take whole-population budgets, commvita gives them the register-driven tools to manage those outcomes (QOF, population segmentation, condition hubs, quality measures), share the record across the neighbourhood, and align incentives to prevention and equity (CORE20PLUS5, shared-savings on avoided admissions).