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This series shares ThoroughCare’s Growth Model. It breaks down each stage to provide a pathway and focus for key strategies and action. These can help optimize performance, outcomes, and revenue at each stage of care management program growth.
The following provides links to each article as they are published for quick reference.
Stage 3: Scalable
Stage 4: Advanced
Stage 3: Setting structure and using tools
Medicare care management programs offer a unique opportunity. For primary and specialty care practices, Accountable Care Organizations (ACOs), and integrated health systems, they can help improve outcomes for high-need patients and generate new revenues.
Yet, while these programs' potential is significant, adding new services, workflows, and complexity often deters providers from pursuing them at scale.
We developed the ThoroughCare Care Management Growth Model (Figure 1) to enable clients to assess their current status and establish iterative growth goals on their path toward sustainable, scalable care management.
In this article, we’ll examine the necessary steps to establish more structured program consistency, streamline patient engagement and workflow, and create scale readiness.
Figure 1: ThoroughCare’s Care Management Growth Model
Mastering the Basics: What should be in place already
Before a program can scale, it must demonstrate that it consistently delivers quality care, meets compliance requirements, and runs efficiently with its current caseload.
This foundation includes having a:
- Clear understanding of and systems to meet guidelines from the Centers for Medicare and Medicaid Services (CMS) for billing, documentation, eligibility, and consent
- Defined scope of services that includes all required elements, such as care coordination, medication reconciliation, health risk assessments, care planning, and goal-setting
- Patient identification, enrollment process, and introductory materials
- Process for billing and reimbursement tracking
- Start-up program staff in place, such as a care manager or program leader
- Manual or initial tools for coordinating activities
Stage Three Growth: Standardizing processes and creating repeatable, compliant workflows
Stage three, as we call it, Scalable, focuses on creating the standards and structures, as well as having the right digital tools, tracking, and data to support a streamlined care management program.
Growth adds volume and complexity. Without standardized processes, things can quickly fall apart.
For most care management programs, such as Chronic Care Management (CCM), the following five processes are essential:
- Care planning
- Time tracking
- Care transitions
- Escalation, supervision, and intervention protocols
- Monthly service delivery and billing workflow
Care planning
Entails creating a comprehensive, patient-centered care plan that typically includes the following areas:
- Diagnoses
- Functional and psychosocial needs
- Goals and barriers
- Shared decision-making documentation
- Interventions and responsible team members
It’s key that any clinicians or care managers delivering program services are aware of policies and standards that outline how care plans should be created, reviewed, and updated.
Any workflows or tools should ensure repeatable and consistent execution across all enrolled patients.
Time tracking
For many care management programs, such as CCM or Remote Patient Monitoring (RPM), CMS requires documentation of time spent on non-face-to-face care activities each month.
Time tracking may seem straightforward, but teams that use manual time logs or spreadsheets tend to struggle to provide sufficient evidence if audited. Manual tools are often inefficient and prone to error at scale.
Again, consistent and standardized methods for capturing accurate time and activities are crucial. For example, CCM requires tracking time and meeting time minimums, such as 20 minutes per patient per month for non-complex care or 60 minutes for complex CCM.
Automated timers, real-time documentation, and role-based activity tracking enable care managers and clinicians to focus on patients and interactions rather than capturing elusive data.
Care transitions
One of the most impactful components of programs, such as CCM and Transitional Care Management (TCM), is helping patients achieve continuity of care across various delivery channels, external providers, and services, or after a hospitalization or ED visit.
Successful programs can consistently follow patients through timely transitions as their health status changes or additional support is needed, in an effort to maintain or recover their previous health and functional baseline.
As care management programs mature, they begin to utilize data and communication proactively to enhance transitions and avoid exacerbations or deterioration. Many utilize resources, such as:
- Real-time alerts from hospital partners or Health Information Exchanges (HIEs)
- Protocols for follow-up calls within 48 hours of discharge
- Checklists for medication reconciliation and care plan updates
- Monthly touchpoints to identify risks that could create acute events and intervene
Failing to manage transitions not only impacts outcomes but also raises costs and patient dissatisfaction, which in turn affects long-term care management enrollment and revenue.
Escalation, supervision, and intervention protocols
Not all care management issues can be handled by care managers alone. As a program becomes established and finds its rhythm and workflow, it’s critical to ensure that the care manager and the clinical team have clearly defined protocols for when a patient requires escalation, as well as roles for who should intervene and how.
In stage three, care teams should know when and how to:
- Escalate to a nurse, social worker, or physician
- Document and track escalations
- Follow up once the patient escalation is resolved and they return to regular care management
- Identify and flag high-risk patients
This structure supports a growing team while maintaining clinical integrity.
Monthly service delivery and billing workflow
By now, the care manager or care team has established their standard approach to regular patient touchpoints, particularly for ongoing care management programs, such as CCM, PCM, RPM, and Behavioral Health Integration (BHI).
Consistent monthly workflows may follow a schedule as shown in the table below, or they could be established at the beginning of each month based on the risks and triage process used to prioritize patients for engagement.
With any approach, however, a tracking system to ensure accurate time capture and meet minimums is crucial for compliant and reimbursable billing. Additionally, having automated systems that identify high-risk or high-priority patients is vital.
Once monthly time, service targets and patient engagement goals are met, the team must rely on standardized workflows and processes to obtain all necessary supervision sign-offs, confirm that billing requirements are met, and create and submit billing documentation.
Stage Three Scaling: Leveraging technology and training for care management growth
Automation and AI technologies aren’t just helpful—they’re essential for scaling an effective care management program.
AI and automation enable streamlined operations
Artificial intelligence encompasses a range of technologies designed to enhance the efficiency of care management.
ThoroughCare’s generative AI and process automation capabilities are the foundation of how the platform streamlines tasks and allows care managers to oversee more patients with better results.
The following seven software capabilities, coupled with targeted training, can transform a manual and inconsistent service into one that is efficient, data-driven, and delivers improved healthcare and value-based performance outcomes.
Automated time tracking
ThoroughCare tracks care manager activities, including calls, chart reviews, and assessments in the background or through time-triggered workflows.
The platform automatically logs time spent during patient interactions and documentation, reducing the need for manual entries while ensuring compliance with CMS billing requirements.
Guided workflows
The platform utilizes templated care management pathways for various programs, including CCM, BHI, and Annual Wellness Visits (AWVs).
Step-by-step guidance is dynamically tailored to the patient’s data and program eligibility, automatically surfacing next steps, reminders, and required documentation based on rules or patient-specific triggers.
Evidence-based assessments
ThoroughCare incorporates validated tools, such as PHQ-9, GAD-7, activities of daily living, and health-related social needs (HRSN) assessments, among others.
The technology ensures that assessments are tailored to the patient's history at each stage of their care plan. Scoring and risk stratification are calculated automatically, and outcomes are tied directly to care plans.
Curated worklists
The platform displays patient worklists that can be filtered by due dates, risk scores, program eligibility, or care manager assignments, making it easy to prioritize patient outreach and manage more patients efficiently.
ThoroughCare utilizes algorithms to identify patients who require urgent attention, such as high-risk individuals who are overdue for contact. The system identifies patterns to highlight where intervention is most critical, thereby reducing the likelihood of missing patients.
AI-supported patient touchpoints
ThoroughCare’s advanced care coordination tools, integrated with CareCo AI technology, enable users to automate many patient engagement processes, including:
- Analyze patient call data and identify follow-up care needs
- Auto-populate AI-generated goals, SMART goals, and interventions posted directly to care plans
- Transcribing patient conversations and suggesting topics for discussion
- Integrate with multiple VOIP systems, including RingCentral
Facilitated documentation
ThoroughCare simplifies compliance and documentation by enabling automated chart updates, providing prepopulated forms, dropdowns, and narrative auto-generation. Integration with partner tools facilitates accurate medication management, enhanced patient engagement, and effective education.
Data analytics, dashboards
ThoroughCare drives scale by making real-time analytics accessible and easy to interpret through filterable dashboards, data visualizations, and reports for tracking KPIs, such as enrollment, time spent, revenue, missed reimbursement, and patient outcomes.
Predictive analytics and anomaly detection highlight trends in utilization, performance, and compliance. Dashboards are tailored to user roles and update automatically with current metrics.
When is care management ready to scale?
Tracking indicators of scale-readiness alert healthcare leaders when their care management program is ready to take on a new patient cohort or when a second or third program can be launched.
Look for the following metrics that may indicate a program is scale-ready, including:
- Documentation passes internal QA reviews 90%+ of the time
- Monthly billing is consistent and increasing
- Patient enrollment retention reaches 80%+ for three months
- Time tracking is automated and integrated
- The care manager and/or team operate from written protocols consistently
- Defined performance metrics are reported and reviewed regularly for three months or more
- New care management team members are onboarded within two weeks
- The current care manager has capacity for more patients
- There is capacity and funds to hire a second or third care manager
ThoroughCare offers software and services to accelerate care management program growth
ThoroughCare helps new or existing care management programs launch and onboard quickly, avoid and mitigate challenges, and build efficiency to reach growth goals.
Through comprehensive onboarding, tailored expert training, clinical and operations best practices, and customizations and integrations of technology, we partner with providers who want to launch, build, and grow a patient-centered, team-based, high-quality service.
