A large portion of American society is in constant need of health care. About 133 million Americans or more than forty percent of the population have chronic diseases, with numbers estimated to reach up to 157 million. Of that number, more than half is projected to have multiple conditions.

Though many patients receive at-home care from family members, not all of them have relatives they can turn to for consistent support. Some families live apart from each other and cannot relocate easily to accommodate their family members with conditions. In cases like these, it may be beneficial to enroll the patient in a chronic care management program.

A care management program can help doctors bridge the gap left by a lack of familial support. These provide qualified patients with a care manager, someone who can help with the daily tasks that often fall upon family or nurses. Many doctors have incorporated care management into their practice. Here are a few tips if you are wondering how to enroll your patients so you both get a good return on investment.


Address individuals, not patient groups


You must understand what your patients need before you can enroll them in a program. Getting a one-size-fits-all plan for your patients may clash with informal care structures they have in place. Perhaps they get visited by various neighbors in the course of the week, or they are reminded online by grandchildren to take their medicine. Take the time to know what they want and figure out what they need from there.

Care teams must decide what program fits which patient. For example, a patient in long-term hospital care needs to have a care management plan designed for transitioning into home care. This means regular follow-ups from your care managers and medication monitoring. Patients are engaged when they know they are cared for.


Don’t start with all eligible patients


Your management program must address your organization’s priorities. Note your patient’s socioeconomic standing, risk contracts, and other factors that can affect the smooth delivery of services. Sometimes, patients are able but not willing; you must also screen your patients for openness to the care program.

It is best to start with pilot testing, on a group or even a handful of people who are willing and able to participate. If you are successful, should be able to replicate your efforts with other groups. Aim for small wins early on, so you can build momentum and gain support.


Understand care management data


Executive teams today have the advantage of access to analytics platforms that can inform their choices. Use data to drive your decisions regarding patient engagement. For example, an analytics platform can show you rising-risk patients. This is a way to gain insight into a patient’s prognosis without extensive consultations.

You can use algorithms to target demographics who have acute conditions. Their frequency of visits to the emergency department or their primary care physician is one indicator. Combined with patient records, you can provide preventive diagnostic tests or recommendations for palliative or hospice care.


It is important to plan a care management program if you are adopting it for the long term. Care management is not going to be successful if it is implemented on its own. It needs the support of the primary care physician, the ED, nurses, pharmacists, and other stakeholders. Finally, to launch a good program, you must consult with an experienced care management company.

We aim to be your only stop for care management. We facilitate remote patient monitoring and help them adhere to a care plan. We do this by scheduling appointments, refilling medication and acquiring patient support systems among others. Get in touch with us to see how we can help.

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