Susan Harkema

An opinion piece in the American Academy of Family Physicians’ (AAFP) FPM journal identified care management as an “essential strategy” for success in primary care practices. Despite growing evidence demonstrating its potential to improve the health of the most at-risk patients, Chronic Care Management (CCM) adoption by rural providers has been slower than their urban counterparts.

Data integration and interoperability enable greater capabilities to capture and share patient information, supporting new models like value-based care management. Access to disparate data sources can streamline and improve the quality of information used in care planning and intervention. Integrated data from educational or evidence-based clinical sources supports accurate and timely patient engagement. Lastly, pushing data back out from systems enables broader team-based care, quality reporting, and communication.

ThoroughCare’s analytics capabilities provide many reports and dashboards that help leaders and their teams manage all aspects of care management, including clinical, financial, and operational performance. This article will provide an overview of a specific analytics report within ThoroughCare. It helps providers identify missed claim submissions and additional revenue opportunities.

Primary care is the foundation of US healthcare. It’s reported that primary care is the “only” area in which providing more services—such as childhood vaccines and regular blood pressure screenings—is linked to better population health and more equitable outcomes. Yet, primary care is struggling. Several drivers are making it harder for physicians to do their best caregiving and patients to receive the timely access they need. Components of an effective care management program are essential to reimagining primary care in the next five years.

So much of a health plan’s business and operational structure revolves around risk and revenue. Whether through underwriting, risk modeling, risk adjustments, risk stratification or scoring, and risk assessments, payors want to reimburse for right-sized care via accurate risk-adjusted payments. As value-based care arrangements become more commonplace, partnering with providers to enhance the accuracy of risk assessment is critical to achieving the health plan’s vision. But how can payors and providers collaborate more to ensure they base risk modeling and scoring on the most timely, relevant, and impactful member data?

The need for tighter payor-provider partnerships has never been greater. Health plans with a 4+ Star Rating dropped from 51% to 42% between 2023 and 2024. Member experience in the provider’s office is directly linked to 70% of all CAHPS survey measures. And in 2023, JD Power reported that health plan satisfaction fell by 13 points. Even member retention rates are hovering at 86%. Providers face their own challenges with increased competition from new care channels like retail, pressures to adopt value-based care, an aging population with more chronic diseases, and shortages causing burnout. While payors and providers have unique challenges and objectives, they also have one common goal—to activate greater member engagement. This goal is foundational to many of the issues that healthcare organizations face today.

According to research published in the journal Primary Health Care Research & Development, there is strong evidence that care management benefits patients and providers by: Increasing patient adherence to treatment guidelines Improving patient satisfaction However, how do care teams ensure patients' and organizational goals are met? Care management was created and became reimbursable because it provides a standardized, team-based, and personalized approach to help patients with chronic conditions. Addressing these comorbidities strives to decrease a patient’s risk of experiencing gaps in care.

Physician practices, payors, and health system leaders rely on key performance indicators (KPIs) to achieve their clinical, financial, and operational goals. For care management programs, it’s key to monitor appropriate measures and trends because it helps providers maximize existing resources. Data metrics can also aid their decision-making to improve outcomes, enhance patient engagement, and lower overall costs.

Physicians and other qualified providers working within nursing and assisted living facilities can deliver covered care management services, according to The Centers for Medicare & Medicaid Services (CMS). So long as they meet all billing requirements, and the claim is submitted using a specific NPI number. These services include: Behavioral Health Integration (BHI) Chronic Care Management (CCM) Principal Care Management (PCM) Remote Patient Monitoring (RPM) Transitional Care Management (TCM) Nursing homes can use these programs, in alignment with a data-driven, team-based approach, to improve chronic disease management, enhance patient satisfaction, and drive additional revenue.

According to the Centers for Medicare & Medicaid Services (CMS), research shows that 5.8 million people in the US do not receive medical care each year due to transportation issues. More recent research from 2022 found that 21% of adults without a vehicle or public transportation went without needed medical care. Related to social determinants of health, these statistics highlight how essential reliable transportation is to accessing healthcare. Limited, unreliable, or unaffordable transportation creates barriers to health by making it harder for patients to attend health appointments, receive medical treatments, or carry out health-related tasks, such as picking up medications or healthy foods.

The Centers for Medicare & Medicaid Services (CMS) reimburses for an optional assessment of social determinants of health (SDOH). When the evaluation is conducted as part of the Medicare Annual Wellness Visit (AWV), the beneficiary will not be burdened by a cost-sharing obligation. The new CPT code G0136 covers the time to carry out a standardized, evidence-based SDOH risk assessment. Beyond detecting SDOH barriers, CMS stresses the need to address them through follow-up and referral to appropriate services. Participating in the two sides of SDOH – identifying and addressing – is part of a continuum of involvement that can significantly impact a patient’s self-efficacy and motivation toward achieving their health goals. Based on a provider organization’s patient care and financial objectives, leaders and clinicians can establish an SDOH assessment and intervention program that fits their capabilities and capacity.

Health behavior change is challenging for most individuals and can be particularly difficult for patients living with chronic health conditions or physical, mental, or social risk barriers. Care management programs and clinical teams can provide personalized and powerful support to facilitate the changes that patients seek. Research has shown the value of goal setting in achieving health behavior changes and the benefit of focusing on particular goal characteristics and aspects of action planning. When goal-setting considers these characteristics, evidence points to improved goal achievement, as well as patient self-efficacy, and provider satisfaction.

Combining Chronic Care Management with Remote Patient Monitoring can improve clinical outcomes, lower total cost of care, and enhance patient satisfaction. Here, we’ll provide guidance on how a provider organization can offer and bill for a combined program while confidently complying with Medicare’s requirements. Synergies of Chronic Care Management and Remote Patient Monitoring

Medicare beneficiary statistics demonstrate the need for some level of behavioral health integration with primary care: 25% of Medicare beneficiaries experience mental illness 40% experience mental illness or a substance use disorder 23% of patients with serious mental illness (SMI) are covered by Medicare 4.2% of total Medicare spending went to mental health services 8.5% went to additional medical spending associated with mental illness One study found that having a mental health disorder was associated with substantially higher spending on other medical conditions, increasing total Medicare spending related to mental health disorders three-fold. Behavioral Health Integration helps primary care treat two types of patient issues

Advance Care Planning (ACP) adoption is picking up steam, but documented barriers keep physicians and patients from engaging more widely. A team-based care management approach can overcome those barriers, yielding numerous benefits for the provider, patients, and their families. ACP benefits can outweigh the effort to overcome barriers Not having ACP documentation and a healthcare proxy can put physicians and patients’ families in challenging situations. They must make decisions without the pa

Care management provides the best opportunity to offer Advance Care Planning. Care management helps deliver personalized, goal-oriented, and team-based care, and offers structure and standards that fit well within Advance Care Planning (ACP). According to the American Academy of Family Physicians (AAFP), the most effective ACP completion rates are seen when a patient receives repeated counseling, which care management already provides. It can help ease time constraints and competing priorities that often prevent ACP discussions.

A performance measurement strategy evaluates whether a care management program has met its goals by using a set of metrics compared against expected outcomes. Through the systematic collection of clinical, operational, and financial data, program leaders can assess outcomes and decide whether to improve or scale the program further. According to the Agency for Healthcare Research and Quality (AHRQ), a successful measurement strategy allows leadership to: - Evaluate program success against expectations - Identify areas for improvement - Fulfill contractual or partnership terms - Build support to scale the program

Studies show that nearly 75% of people will need help making medical decisions. Less than 25% have formally documented their end-of-life care wishes. Provider organizations, through Medicare reimbursement for Advance Care Planning (ACP) services, are working to change these statistics. Their goal is to help patients prepare for future medical decision-making in case they are seriously ill or unable to communicate their preferences. However, having the care planning discussion and documenting a patient’s wishes through a Living Will and a durable Healthcare Power of Attorney (HCPOA) are ineffective if key people aren’t aware that they exist, and the documents can’t be easily accessed.

ThoroughCare's clinical team recently hosted a webinar, “The Impacts of Social Determinants of Health (SDOH) on Patient Care and Outcomes.” They were joined by Dr. Maya Bell, PharmD, MBA, Director of Clinical Services at PharmaClin. As a clinical pharmacist embedded in a rural-based, family medicine clinic in North Carolina, Dr. Bell provided real-world insight into the value of approaching SDOH issues. She also gave recommendations for creating a compassionate and practical approach.

Since 2015, the Centers for Medicare & Medicaid Services (CMS) has established several care management programs to improve outcomes and reduce costs for beneficiaries with chronic conditions and higher complexity. These include: Behavioral Health Integration (BHI) Chronic Care Management (CCM) Principal Care Management (PCM) Remote Patient Monitoring (RPM) Transitional Care Management (TCM) These programs enable provider organizations to enhance patient value and outcomes and improve fee-for-service revenue. Additionally, programs can be used in tandem to harness complementary features and maximize patients’ physical and mental health. It is common for providers to feel uncertain about how to manage programs that are implemented concurrently or synchronously.