Care Management Blog

What You'll Learn Reading This Article Patient-Centered Care Plan Definition: A patient-centered care plan is a collaborative, living document owned by the patient and shared across the care team to tailor treatments, goals, and interventions to an individual’s unique physical, emotional, and social needs. Clinical and Financial Benefits: Implementing individualized care planning improves patient satisfaction, enhances medication adherence, reduces fragmented care, and actively mitigates billions of dollars in wasted healthcare spending caused by poor care coordination. Value-Based Care Alignment: Ongoing care management programs—such as Medicare’s Chronic Care Management (CCM)—leverage patient-centered planning to streamline clinical workflows, hit value-based metrics, and drive recurring fee-for-service reimbursement. The ThoroughCare Solution: As a comprehensive care coordination platform, ThoroughCare enables clinical teams to seamlessly build these evidence-based, patient-centered care plans through guided workflows, risk factor analysis, and CMS-compliant tracking. Many physicians and clinicians pride themselves on the relationships they develop with their patients. By creating a patient-centered care plan, providers can enhance engagement, deliver timely interventions, align on outcome goals, and improve care team coordination.

Substantial evidence supports the benefits of patient engagement in healthcare. Studies have shown that engaged patients experience better health outcomes, including reduced hospital readmissions and improved chronic disease management.

More than 60% of older Americans receive help from unpaid caregivers; typically, these include family, friends, or neighbors. Engaging family as part of the patient’s overall care team has been shown to improve chronic disease management, including:

The US Center for Disease Control and Prevention defines health literacy as "the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others."

Increased economic pressures squeeze health plans, and providers seek relief from burnout and revenue loss while wanting to improve outcomes. Both parties are looking for ways to achieve cost reductions, enhance quality, and better the healthcare experience.

Advance Care Planning (ACP) adoption has been slow because clinicians don’t have ample time or are uncomfortable with the topic; patients tend to associate ACP with end-of-life.

Physicians and clinical teams face a catch-22. They can’t gain patient participation and adherence without increasing health and disease education. Yet, they don’t have the time to engage patients deeply.

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.

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.