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How to Design a Care Management Performance Review Process

Written by Kathryn Anderton, BSN, RN, BC-RN, CCM | Apr 24, 2025 7:45:02 PM

Periodic performance reviews are crucial to ensuring any care management program meets its objectives. However, creating a process and determining which data to focus on can be challenging for a new or expanding program.

A care management performance analysis process can be customized for a provider’s goals. Armed with this information, care managers can identify areas of success, quality improvement opportunities and make data-driven strategic decisions.

ThoroughCare, a leader in care management best practices, supports clinical workflow development with expert advice and a software platform that simplifies compliance. We help providers design performance review processes and use comprehensive data to improve care delivery. 

In this article, we’ll cover a few key points to consider in a care management review process. ThoroughCare is recognized by the National Committee for Quality Assurance (NCQA). 

Our platform is NCQA Prevalidated for Population Health Management in Health Plan Accreditation. 

Care management performance review process

Figure 1 lays out a five-step process for care management performance monitoring. 

These five steps include:

  • Prioritize performance metrics based on objectives
  • Data collection
  • Data analysis and trends
  • Performance discussion and quality improvement suggestions
  • Action plan and next steps

Figure 1: Five-step care management performance metrics process.

Establishing a performance review schedule and having a repeatable process are essential. 

Some key performance indicators (KPIs) should be reviewed monthly, while others may be better suited for quarterly or semi-annual reviews.

As you create a desired metrics list—or review data analysis, dashboards, and reports available in ThoroughCare—make note of which should be reviewed at what interval.

In addition to clinical workflow development and training, ThoroughCare’s Clinical Advisory Services can also provide care management performance reviews. Experts are equipped and experienced in assessing CMS compliance, operational output, billing and reimbursement practices, as well as clinical quality and care standards.   

Step 1: Prioritizing performance metrics based on objectives

Consider the following four foundational performance areas as part of your review process, including:

Depending on your care management goals, you may want to consider other metrics, such as population health and KPIs related to specific care management programs. These could include Chronic Care Management, Remote Patient Monitoring, Transitional Care Management, or Annual Wellness Visits.

In order to prioritize performance metrics, review the program goals set when the care management program was established.

  • What precipitated starting a new care management program?
  • What specific patient, program, or organizational outcomes were important?
  • How have program goals evolved and changed?
  • How would you know that your care management program is successful?

According to the Agency for Healthcare Research and Quality (AHRQ), it’s vital to understand the motivations for creating or expanding a program and select metrics that indicate progress on goals.

They highlight several reasons providers launch care management programs, including:

Quality improvement: Care management aims to improve healthcare quality, care coordination, and service delivery, particularly for beneficiaries with chronic conditions.

Cost Savings: In addition to care quality and clinical outcomes, some programs aim to reduce care costs, particularly when the program is part of a value-based contract.

Supplemental revenue: Most programs have multiple goals. Medicare care management programs can add fee-for-service revenue to enhance patient services.

How to collect and report on performance metrics 

After clearly identifying the performance metrics you want to assess and how often, steps 2 and 3 focus on data collection and analysis.

Step 2: Data collection

Various KPIs can be tracked via dashboards and reports, such as within ThoroughCare, across four performance review areas. Here is a sampling of data points available within each area:

Clinical and patient outcomes metrics

  • Medication and allergy – view of medication history, adherence, and allergies
  • Abnormal lab results – results that fall outside the normal reference range
  • Gaps in care – specific data related to key diagnoses, such as diabetes and hypertension
  • HRSN details – patients at higher risk due to social factors
  • Preventive care compliance – rates of screenings, vaccinations, and wellness visits
  • Immunization details – vaccination status
  • Stratification – identify patients with specific needs
  • Vitals – historical trends across patient vitals
  • Quality audit – monthly medication reviews, significant care plan types, potential gaps in care
  • Calendar report – call volume, performance, and workload per user
  • Care plan statistics – care plan effectiveness and patient outcomes by goals, barriers, interventions, and progress
  • Expected outcomes – insight into specific conditions and expected changes
  • Goals – overview of goal-related metrics, Smart goal trends, average time to achieve goal
  • Interventions – trends of interventional impact over time, patterns, progress
  • Problems and symptoms – frequency, severity, and trends

Patient enrollment and engagement metrics

  • Enrollment history details – comprehensive view of enrollment trends, changes, and patterns
  • Engagement – engagement status over time, insights into patient behavior, preference, and interactions
  • Inactive patients – patient attrition and reasons for inactivity
  • Monthly engagement status – level of engagement and interactions
  • Outreach – call trends, volume, and call outcomes
  • Successful call details – in-depth analysis of details of successful calls
  • User performance review – user behavior patterns and engagement levels across total patients, new patients, and established patients
  • User statistics – 12-month view of activity, productivity, and outcomes

Care management and operational efficiency metrics

  • Analytics – active patients per program, total time logged per month, top 10 conditions, care plan resolutions, and billable claims
  • Notifications report – view of pending notifications, when messages were read/archived, and response times
  • Care manager statistics – productivity, patient interactions, and outcomes

Financial metrics

  • Claims – volume of claims generated over period, identify peaks and trends, claim details by practice, program, and billable date
  • Missed reimbursement – monitor and address any missed reimbursement opportunities with program claims

Using this data, providers can assess the overall value of care management services and calculate return on investment. A previous blog provides a more in-depth review of KPIs covered through ThoroughCare.

Population health and care management program-related metrics

Other metrics complement the four assessment areas mentioned—clinical, operations, engagement, and financial. Those include data related to population health and specific care management programs.

ThoroughCare provides a variety of population- and program-based dashboards and reports. 

Here are a few areas that may be useful as part of a performance review process.

Population health

Reviewing population health metrics complements individual patient and program trends, giving insight across various patient cohorts, including:

  • Conditions – current diagnoses and top conditions
  • Population health management – Fall risk, life planning documents, overall health rating, resource barriers, ADLs/IADLs by patient demographics

Chronic Care Management

  • CCM data – patient health outcomes, care team efficiency, and overall program effectiveness, including patient engagement, participation, and inactivity over time

Remote Patient Management

  • RPM data – performance, effectiveness, and outcomes, including alert notification, abnormal health metrics, patient engagement and interactions, calls, time, and claims generated
  • RPM opportunities – patients who may benefit from RPM management to improve outcomes and overall health

Transitional Care Management

  • TCM data – monthly discharges, patient complexity, patient state and status, incomplete reasons
  • TCM reports – overview of key components and performance, including volume of follow-up visits completed, discharge summaries, medications, and recommendations

Annual Wellness Visit

  • AWV data – specific risk factors, preventative measures, completion, and incomplete details and trends
  • Health risk assessment – outcomes, patient risk level, assessment schedule and completion trends

Step 3: Data analysis & trends

Data can provide insights and visualizations of performance trends and patterns or offer comparisons against previous periods. Providers can create overview documentation and presentations that demonstrate progress and benchmark to industry standards.

ARHQ suggests that organizational policies and interventions work together to impact provider and patient behavior. If the interventions are effective, they should lead to high-quality clinical care and effective patient self-care. These will yield desirable health and economic outcomes.

They recommend looking at the program process, intervention impact, and health outcomes to answer three questions from the collected data:

  • Are program interventions and policies being implemented as planned?
  • Are program interventions and policies yielding their intended results, such as high-quality care and effective self-care?
  • Is the program resulting in meaningful changes in health and economic outcomes?

Using data to make quality improvement decisions

Step 4 focuses on discussing the trends and patterns in light of the questions posed and program goals. Step 5 finalizes the process by creating an action plan for improving results for the next reporting period.

Step 4: Performance discussion and quality improvement suggestions

After celebrating successes, identify gaps in performance.

  • What are the root causes for falling short of your goals?
  • What reasonable improvements could be made before the next reporting period?
  • What barriers might the team face to achieve these improvements? And how can we plan to avoid them?
  • What suggestions does the team have for overall process and performance analysis enhancements?

Step 5: Action plan & next steps

The final step establishes strategies for improvement. 

This is the time to prioritize the next steps, assign action items and responsibilities to team members, and set deadlines for follow-up.

ThoroughCare provides comprehensive KPIs for improving care management performance

ThoroughCare’s reporting and analytics capabilities provide KPIs needed for robust oversight, compliance, and management of care programs. 

The easy-to-use reports and dashboards also support quality and performance improvement, ensuring a program meets its care delivery and patient goals.

Key questions answered

How should care management leaders assess their program’s performance?

Consistent and regular review of care management program performance is essential to achieving clinical, patient, and financial goals. Using our care management performance review process, initiate the following steps:

  • First, be clear on desired program objectives.
  • Identify which Key Performance Indicators are necessary to collect and review at what interval.
  • Next, collect desired metrics by creating or accessing reports and dashboards.
  • Conduct analysis and gather insights from trends, progress, and gaps.
  • Share and discuss analysis results and determine areas of success and where quality improvements should be prioritized.