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.
Depending on the program and patient complexity, the monthly minimum billable time for care management activities could be 20, 30, or 40 minutes or more.
The purpose of each program is threefold: to improve the patient’s health status, reduce emergency department and hospital utilization, and decrease overall healthcare costs. And monthly touchpoints are critical to making meaningful, long-term changes.
Care managers, overseen by a physician, are clinical staff holding licenses like LPN, RN, NP, MA, PA, or LCSW. By using the following guidance, they can optimize each touchpoint to achieve person- and program-centric objectives.
Focus on five areas for monthly patient engagement
Once identified as a care management candidate, patients are then introduced to their relevant program, give their approval to participate, enroll, and work with their care manager or other clinicians to create their initial care plan.
Each monthly contact provides dedicated time to focus on a systematized yet personalized approach to achieving five objectives. These are:
Build connection and rapport: Every monthly call or virtual session allows staff to engage the patient while building trust and sharing. Deeper connections can bolster a patient’s dedication and confidence to make positive change.
Check-in on goal progress and challenges: Discuss the patient's progress on the goals and actions established in the care plan. Uncover any challenges they face and if they can overcome them or if support is needed.
Determine ways to support patient success: Provide guidance or education, community resources, and help with coordination or addressing barriers to goals.
Document any changes: Capture information that indicates changes in a patient’s condition or symptoms that may require clinical intervention or updates to the existing care plan.
Reinvigorate motivation and encourage action: Regular engagement can reconnect patients to the excitement and positivity of achieving their personalized goals through improving their health. Additionally, look for opportunities to bolster self-management and care plan adherence through education and building greater health literacy.
Four steps to prepare for each patient interaction
ThoroughCare makes monthly patient interactions seamless and easy to manage and document. In a busy care management program with numerous patients to engage each day, a care manager can take just a minute or two to prepare mentally before contacting the patient to ensure a productive and patient-centric interaction.
The plan: Quickly review the patient’s care plan and priorities.
The last contact: What were the outcomes since the previous contact? What direction are you heading with this patient?
Your focus today: What are the priorities for today? Find a space to balance the tasks to complete and the patient’s current state. Demonstrate compassion and concern while also staying focused on the plan.
Your attitude: Take a moment to think about this patient. Who are they? What is important to them? Use mindfulness to be present and available to the patient’s needs.
Once the care manager is mentally prepared to engage with this patient, they are ready to leverage their most valuable tool toward patient engagement and meaningful progress…the care plan.
The care plan is the foundation for each touchpoint
Every enrolled care management patient should receive a comprehensive care plan. The plan is the compass by which all activities, decisions, and goals are oriented.
According to The Centers for Medicare & Medicaid Services (CMS), a care plan typically includes, but is not limited to, these elements:
- List of current health conditions
- Expected outcome and prognosis
- Measurable treatment goals
- Medical, cognitive, functional, and behavioral assessment
- Symptom management strategy
- Planned interventions with an expected timeline
- Complete medication list
- Recommended preventive actions
- Environmental evaluation and social determinants of health
- Resources and support assessment
- Interaction and coordination with outside resources, practitioners, and providers
Care plans are most effective and actionable when written collaboratively between the patient and clinical staff with oversight by the patient’s physician.
During each monthly interaction, a care manager will assess the patient’s well-being, adherence to the care plan, and progress towards meeting goals.
Care managers should ask open-ended questions to engage the patient. Some questions to ask may include:
- How have you been feeling, have there been any significant changes in your health?
- Tell me about your goals and aspirations for your health
- What has been helpful in managing your goals and what challenges have you faced?
That last question serves as an opportunity to discuss a patient’s motivations. Doing so can reinforce the value the patient receives by participating in the care management program.
ThoroughCare documents and tracks goal progress within patient care plans.
ThoroughCare makes care management seamless
ThoroughCare provides every feature needed to easily engage with and stay on top of care management for many patients. Through motivational interviewing, SMART goals, guided clinical assessments, and easy-to-navigate workflows and checklists, ThoroughCare ensures that patients are the center of attention while documenting time and care plan updates for billing and compliance.
Look for information that may require clinical intervention or care plan changes
The opportunity to assess symptoms or if a condition has worsened and requires clinical intervention is one of the most important aspects of regular patient engagement.
As the care manager reviews the care plan and actions taken, questions about symptoms and the patient’s current abilities, compared to previous information, may trigger additional questions and follow-up with their physician or care coordination of other services.
You should determine if immediate triage is required or if new information merits changes in the overall care plan, along with physician approval.
Debrief every monthly patient touchpoint
Lastly, just as the care manager can take a moment to prepare for the patient interaction, they should debrief the call with a couple of quick questions. These can solidify next steps and provide a mental review to continuously improve program quality, as well as engagement with the patient.
How did the call go? Pick 1 item that went better than expected and 1 item that could have gone better.
What commitments were made? Document what steps you or the staff will take and what the patient is committed to doing over the next month.
How did (or didn’t) today’s touchpoint move the patient closer to their goals? What did I learn that I can use for all future patient contact or specifically for engaging with this patient?
Here are four best practices to promote efficiency when engaging patients:
Set patient contact goals:
- Establish a set number of 'new patients' to reach each month and each day out of the total number of patients enrolled in the care management program. Setting these target goals is often overlooked but is invaluable when deciding who should be contacted and when.
Time your calls for success:
- Most patients don't answer the phone early in the morning. Schedule initial contact for the late morning and follow-up calls for the afternoon to maximize successful engagement.
Sort your worklist and focus on reaching 20 minutes:
- Use ThoroughCare’s worklist to sort patients by minutes to focus your contact on reaching those patients who have less than 20 minutes. This ensures each patient receives adequate attention and that your efforts meet the billable threshold.
Leverage the worklist to prep for contact:
- Again, using ThoroughCare’s worklist, reference the call columns to quickly identify information needed before starting daily outreach, including how many attempts have been made, what was discussed on the previous call, etc. It saves time from digging into a chart to identify key points for discussion. It also ensures that care managers adhere to policies on the number of attempts to reach a patient before potentially inactivating them.
- Lastly, using the clinical review tab in ThroughCare, care managers can quickly find last month's progress and identify which topics need follow-up, including resource difficulties or missed doctor’s appointments.
ThroughCare provides all relevant patient information in one location, which saves time and reduces the risk of missing key points when speaking with the patient.
ThoroughCare streamlines monthly touchpoints so care managers can focus on patients
At ThoroughCare, our software solution revolves around the care plan model. It provides content and workflows created by clinical staff designed to engage people.
Our care plan creation and management modules offer guided interviews that your staff can utilize when interacting with patients on a monthly basis. Our pre-written questions make it easy to cover the key elements and keep your patients’ care services on track.
