Launching a new Medicare care management program, such as Chronic Care Management (CCM), Behavioral Health Integration (BHI), or Remote Patient Monitoring (RPM), presents a unique opportunity for providers to improve health and care for seniors while generating a new revenue stream.
However, many organizations hesitate to begin due to concerns about staffing, upfront costs, and compliance burdens.
The good news is that a successful care management program doesn’t require major workflow and staffing changes or risky investments.
The following seven low-risk, high-return strategies present a phased and measured approach.
They enable providers to launch their first or next care management program with minimal disruption and excellent potential for return on investment.
1. Establish clear program goals and purpose
An essential first step is having clear reasons for starting. A vision for achievable, positive outcomes.
Providers that aren’t sure what success looks like, that just want to increase revenue, tend to face more obstacles, delays, and flounder to attain meaningful results.
For example, clinical goals for a new Chronic Care Management (CCM) program focused on patients with both diabetes and hypertension, who have experienced two or more hospital admissions in the past year, could include:
- Improve diabetes management by reducing the average hemoglobin A1c among enrolled diabetic patients by 0.5% within 6 months of enrollment.
- Improve hypertension control by achieving blood pressure control (<140/90 mmHg) in 75% of hypertensive patients within 4 months.
- Reduce 30-day hospital readmission rates among CCM participants by 20% within 6 months compared to baseline.
Other program goals should focus on areas such as enrollment, finances, and sustainability. Sample objectives could include:
- An enrollment goal could be to onboard 50-100 eligible Medicare patients into a Chronic Care Management program within the first 90 days of launch
- A billing goal might include $10,000 in reimbursed CCM services within the first 4 months by submitting accurate claims for CPT 99490 and 99439
- A patient engagement goal could be to maintain at least an 85% completion rate of monthly 20-minute CCM contacts with enrolled patients by the end of the second quarter
2. Test outsourcing or conduct an insourcing pilot
Outsourcing care management
Care management service providers, the companies to which physicians and their practices outsource their programs, are becoming increasingly popular and with good reason.
Outsourcing can be an invaluable way to test the waters and see if launching a care management service is the right move. Also, working with a service company can be a first step toward scaling and bringing the service in-house, if desired.
These vendors should provide the technology, clinical staffing, documentation tools, and billing support needed to run a compliant and efficient program. Some vendors even offer performance-based pricing or shared-risk agreements.
Carefully vet companies using our guidance.
Insourcing care management
Clinicians and provider leaders who want to start a care management program internally can save time and avoid mistakes by collaborating with ThoroughCare to conduct an initial pilot.
Partnering provides easy-to-use, comprehensive software to launch and implement a program, and it offers access to clinical, technical, and operational advisory support and training.
This significantly shortens the learning and growth curve while mitigating many of the risks new programs face.
Begin with a small, manageable group of eligible patients, perhaps 20 to 50, to test workflows, identify operational gaps, and assess billing processes. This limited rollout minimizes exposure and gives the care team the opportunity to learn and adapt before scaling.
3. Conduct proof of concept with a focused patient population by risk, disease, or acuity
Not all patients are equally suitable for care management programs. Focus initial efforts on high-yield populations. These include patients who not only meet Medicare’s eligibility requirements but are most likely to benefit from added care coordination.
Use existing patient data to identify the most appropriate and in-need cohort that aligns with program goals. Then, upload patient information directly into ThoroughCare, or work with our Technical Services Team to integrate data and seamlessly launch a new program.
Criteria for an initial patient cohort should include those who would benefit from it. Which patients would make good pilot candidates for the team to launch the service?
4. If insourcing, use technology that optimizes AI and automation
While electronic health records (EHRs) have their place, care management software is essential for optimizing efficiency and maximizing outcomes.
Unfortunately, EHRs were not designed for the types of tasks that care management and care coordination require. This includes:
- Evidence-based assessments
- Patient-centered care plans
- Patient education and engagement
- Automating CMS time, documentation, and billing compliance
Technology should facilitate an efficient and effective new program, not complicate it. ThoroughCare’s care management platform allows you to start small and add programs, patients, and customization as needed.
The right technology leverages artificial intelligence (AI) and automation capabilities to streamline critical administrative tasks. This helps track performance and makes it easier to scale the program across different locations or provider types.
Automating purpose-built workflows significantly reduces staff burden and accelerates onboarding.
Using templated scripts, automated call capture, and context-aware prompts enables care managers to attend to patients more than worry about capturing data.
5. Use analytics to monitor goals, iterate, and adapt
The key to early achievements and growing from a small program to a robust, sustainable, and scalable one is the ability to use data to improve, iterate, and adapt quickly.
Having easy access to usable and insightful data is essential. ThoroughCare delivers near real-time key performance indicators (KPIs) on essential elements needed for care management programs, including:
- Clinical
- Compliance
- Billing
- Operations
- Workflow
- Engagement
- Enrollment
Staff and leaders can use dashboards, worklists, and reports to identify issues or study successes.
Examples of ThoroughCare’s robust analytics and data visualizations include:
Patient stratification report: Provides a wealth of information across a patient’s clinical profile. Identifying high-risk patients across multiple categories enables providers to view patient data more effectively, optimize care delivery, improve patient outcomes, and ensure the efficient use of resources.
Patient outreach dashboard: Offers a detailed view of call scheduling trends, performance metrics, and operations. It supports call volume and pattern analysis by recording the date and time of every call, tracking call outcomes.
Claims dashboard: Monitors and analyzes claims processing, highlighting the volume of claims generated over a specific time frame. This can help identify peaks and trends, as well as areas where revenue was lost due to not meeting minimum service minutes.
6. Engage and educate patients early and often
Patients are more likely to enroll in care management services when they understand the benefits. Positioning a new program should focus on its value as an extension to core services. Patients receive better access, more support, and personalized attention to achieve individual health goals.
ThoroughCare offers:
- Integrated, evidence-based education
- Automated communication
- Guided touchpoint scripts and materials
This helps streamline patient enrollment in programs.
7. Solicit support and training to ensure compliance
The final strategy is fundamental to both initial and long-term success: Ensuring compliance with Medicare’s program requirements.
Compliance with Medicare care management requirements
Sustained revenue from Medicare (CMS) programs depends on consistent compliance with CMS regulations. One of the highest-risk areas is documentation. Each service must meet specific time, content, and billing criteria, and this must be clearly recorded.
ThoroughCare provides functionality to document every interaction, log time precisely, and store patient consent and care plans properly.
Train staff for the skills that make the most impact
Our Clinical Advisory Team provides tailored training, so that teams can not only master the technology but also understand their program’s CMS requirements.
We also prioritize novel skills that create positive change with patients, such as motivational interviewing, SMART goals, and patient-centered assessments and care planning.
Partnering with ThoroughCare increases early care management success
A Medicare care management program can be a win-win for providers and patients—but only if implemented strategically.
These strategies focus on minimizing risk while maximizing return, providing a roadmap that has proven effective with clients time and again.
If you're considering launching a care management program and want help building your plan, tracking metrics, or evaluating vendors, reach out to discuss your goals. A strategic start today can yield significant results in patient health and practice performance tomorrow.
