There are numerous benefits to launching a care management program. These include measurable results for patients, such as improved healthcare access, efficiency, and health outcomes, as well as cost savings for Medicare, Medicare Advantage, and even commercial payors.

Medicare’s care management programs, such as Principle Care Management (PCM), Chronic Care Management (CCM), and Behavioral Health Integration (BHI), all rely on monthly patient engagement, typically conducted via phone or virtual care.

Healthcare’s goal is to cure. However, Advance Care Planning (ACP), or end-of-life planning, can address the tension between care at all costs and ensuring an individual’s wishes are met when they can’t speak for themselves.

Medicare’s Annual Wellness Visit (AWV) can be instrumental in improving care quality for older adults. This yearly assessment captures information about a patient’s health and functioning to document disease and identify new or worsening risk factors.

Several factors are driving the adoption of team-based care coordination. Workforce shortages exacerbated by the pandemic, a growing population of adults living longer with chronic disease, and the shift toward value-based care models top the list.

Unaddressed health-related social needs (HRSN) can make achieving care plan goals difficult.

Policy and value-based payment models promote the importance of managing transitions of care.

Patient assessments are used in various settings by different medical professionals. They can be part of a proactive process (e.g., during an Annual Wellness Visit) or when some symptoms or signals indicate further assessment is necessary.