Outcomes Management in Health and Social Care: How Care Management Can Help

The primary goal of Medicare care management is to improve patient health outcomes. By providing proactive, ongoing care, care management empowers patients to take control of their conditions and set goals for improving their health.

Care management has the power to improve patient engagement and treatment adherence, to provide education and resources, and to encourage proactive care and early treatment. By focusing on these areas, Chronic Care Management (CCM) and Advanced Primary Care Management (APCM) can lower patients’ cost of care, their number of ER visits, and their hospital admissions and readmissions.

CCM and APCM are uniquely well-equipped to address outcomes management because they are not limited to a specific period of time, as Transitional Care Management and similar programs are. Rather, they focus on providing ongoing care to patients for as long as they’re enrolled.

Keep reading to discover how care management can improve long-term patient outcomes for Medicare patients at your practice, and to learn more about the distinctions in how CCM and APCM impact health and social outcomes.

Engage Patients in Their Healthcare

Care management programs offer multiple opportunities to engage Medicare patients in their care. Between working, time with loved ones, and pursuing hobbies or passions, it’s easy for patients to forget about or deprioritize following their treatment plans between appointments.

Chronic Care Management and Advanced Primary Care Management both offer patients a comprehensive care plan and a care manager to follow up with them. The care manager can help patients set SMART (specific, measurable, achievable, realistic, and time-based) goals to improve their health.

These goals give patients a clear path to take charge of their health. Rather than focusing on vague goals like “eat healthier" or “exercise more,” patients can pursue specific goals like “Walk 20 minutes a day, 5 days a week.” Their care manager can provide encouragement during regular check-ins and help patients create new goals once they achieve their former ones.

Having regular check-ins also promotes accountability. Patients receive frequent reminders to prioritize their health when they have check-ins once a month (under CCM) or on a cadence based on their needs (under APCM). They can also receive education to help them pursue their goals.

Provide Personalized, Accessible Patient Education

When engaging patients in their healthcare, it’s critical to ensure patients have access to accurate, comprehensive health education.

Education should be:

Available in multiple formats (digital, print, video)
In a language a patient can comfortably read
Delivered at an accessible reading level
Tailored to a patient’s conditions

Some patients prefer to receive education via text or email, while others prefer videos or printed materials. It’s also important to ensure that educational materials are presented in a language that patients speak fluently. While patients may understand multiple languages, they will likely need to receive in-depth health information in their first language.

Even when patients are reading in their first language, the American Medical Association recommends that patient education be written at approximately a sixth-grade reading level for the best comprehension. Education should also be closely tailored to the health conditions a patient lives with, so they can understand the relevance of the materials.

Education and Engagement Through Care Management

Providing education that meets all of these requirements helps engage patients in their health. But searching out and sharing personalized education for individual patients can prove difficult for overworked practice staff.

Since care managers reach out to patients multiple times a year, they have frequent opportunities to offer education. Some care management vendors, like ChartSpan, also have access to education programs that ensure materials are reviewed by clinicians and written at an appropriate reading level for patients.

Care managers can pick out the materials that suit a patient’s health needs and text, email, or mail them relevant materials. Both APCM and CCM require offering patients a choice of multiple communication methods, making it easier for practices to provide accessible education and keep patients engaged in their healthcare.

Encourage Greater Treatment Adherence

Improving medication and care plan adherence can lower the risk of symptoms recurring, rates of ER visits, hospitalizations, readmissions, and even mortality rates. However, patients can fail to adhere to treatments for a wide variety of reasons.

Some of the most common reasons for lapses in treatment adherence are:

Not understanding the need for multiple medications
The time burden of managing medications or lifestyle changes
Socioeconomic barriers, such as cost or ability to reach the pharmacy

Care management programs can help address all of these barriers. Ongoing education and engagement ensure patients understand why medication or lifestyle changes are necessary and how their decisions can impact their health. Care managers can also provide reminders, encouragement, and help with planning to ensure adherence remains a priority among patients’ other obligations.

How Care Management Can Assist with SDOH Obstacles

When patients face socioeconomic obstacles to treatment adherence, like not being able to afford their medication or having trouble reaching the pharmacy, their care manager can step in to provide resources and improve their health outcomes.

In the past, ChartSpan care managers have been able to direct patients to medication delivery services and to resources to help them afford their medication. They have also assisted with treatment adherence by providing transportation services to take patients to appointments, suggestions of exercise groups in their area, and food pantries or delivery services that offer healthy food options.

For example, one patient expressed that she struggled with food insecurity, but the food pantries in her area only offered canned food that didn’t meet her recommended dietary guidelines. Her care manager found a local service that could deliver fresh produce to her door and sent her information on how to sign up for the program. The patient was delighted to have reliable access to fresh, healthy food that allowed her to pursue her health goals and adhere to her treatment plan.

Coordinated Care Across Patients, Care Managers, and Providers

Fragmented care, care that is poorly coordinated among multiple providers or organizations, can lead to preventable ED visits, overutilization of healthcare services, and increased costs. A patient may receive the same diagnostic tests multiple times, leading to an unpleasant patient experience and higher healthcare costs. Or, even more worryingly, they may have medication or treatment contradictions that lead to hospitalization and worse overall health outcomes.

Care coordination as part of APCM or CCM can help prevent these negative outcomes. Care managers can check in with patients regularly on their recent appointments, medications, and treatment guidance.

If the provider offering care management isn’t aware of a patient’s visit to another practice, the care manager can update the patient’s records and alert the CCM or APCM provider. The care manager can also alert providers to new medications patients have been prescribed or changes in the patient’s blood pressure, A1C levels, or other health measures that may require intervention.

Proactive Assessments

When patients’ care is fragmented or infrequent, they may have unspoken needs or gaps in care that go unaddressed. Care management programs empower care managers to perform regular screenings or assessments, such as:

Condition Awareness
Activities of Daily Living
Durable Medical Equipment
Fall Risk
Cognitive Assessment
Medication Adherence
Social Determinants of Health

If these screenings show that the patient has unmet needs, the care manager can provide educational or community resources and alert the practice to areas where the patient may need help. This process prevents patients from falling through cracks in the healthcare system.

Addressing Gaps in Care

Care management also offers multiple opportunities to address gaps in care, such as missing vaccinations, screenings, or blood pressure and A1C readings. Care managers can take into account both what gaps in care a patient has and which quality measures are most important to the practice before deciding which gaps to prioritize.

While quality has always been an optional but valued component of Chronic Care Management, it is a mandatory component of Advanced Primary Care Management. APCM care managers must actively seek out gaps in care that are common in a patient population, often through a national database, and address those gaps in care by administering surveys, collecting data, and encouraging patients to visit their provider for missed vaccinations or screenings.

By addressing these gaps in care, care managers help practices improve their quality measures, while also providing proactive care that lowers patients’ risk of needing to visit the ER or be admitted to the hospital.

24/7 Access to Care and Ongoing Support

Advanced Primary Care Management and Chronic Care Management both offer a 24/7 care line for patients to call with concerning symptoms or when they need someone to talk to. A well-equipped care line will include nurses who can provide triage when needed and direct patients to the ER, urgent care, or their provider.

By ensuring patients receive the right level of care, triage nurses prevent avoidable ER visits or hospitalizations. In the past, ChartSpan triage nurses have been able to help patients receive care for conditions ranging from the common cold to elevated blood pressure, falls, heart attacks, and mental health crises, using Schmitt-Thompson protocols to effectively determine when the patient can be referred back to their provider or when they need to immediately seek emergency care.

Addressing Symptoms Over Time

While 24/7 access to care is critical for emergency symptoms, care managers also offer recurring, proactive care. APCM and CCM both include a mix of outbound patient outreach and taking inbound calls from patients who need support.

For example, one patient reported his blood pressure as being 140/98. Over time, he and his care manager created a care plan and goals to lower that number. His care manager helped him set appointments with his provider and provided education on how to improve his blood pressure through lifestyle changes, like diet, exercise, and stress management. In just five months, his blood pressure dropped to 120/72, and after eight months it dropped to 120/70.

Through recurring care, combined with 24/7 access, patients feel connected to care at all times, and can continue to make their health a priority between appointments or while busy with everyday life.

The Impact of Care Management on Health Outcomes

Through patient engagement and education, increased treatment adherence, greater care coordination and 24/7 availability of care, care management programs can improve patients’ long-term health outcomes. A national report based on CMS claims data showed that Chronic Care Management reduced hospitalization claims by 4.7% and costs by $888 per beneficiary, per year.

An analysis of ChartSpan claims data showed even more dramatic results, with hospitalization claims dropping by 36% and costs reduced by $2,457 per beneficiary, per year. Spending less on healthcare benefits patients and practices’ quality performance, but reducing those costs through reducing hospitalizations also dramatically improves patients’ quality of life.

ChartSpan Chronic Care Management was also able to lower ED costs by 19% and hospital readmission rates by 52%. These figures indicate patients are better able to proactively manage their health at home with the help of their providers and care managers, without ER visits or hospital readmission becoming necessary.

Because Advanced Primary Care Management didn’t launch until 2025, there is less available data to demonstrate its efficacy. However, since it offers so many of the same features as Chronic Care Management, it is likely to have similar results on hospitalization, ER visits, hospital readmissions, and overall healthcare costs.

Launching Care Management Programs as Part of Outcomes Management

If managing patient health and SDOH outcomes is a priority for your practice, care management programs like Advanced Primary Care Management and Chronic Care Management can play a critical role in connecting patients to proactive, ongoing care.

A well-run care management program combines care access, patient education, care continuity, community resources, and patient engagement to improve outcomes for patients with a variety of health conditions and socioeconomic challenges. To learn more about care management and its impact on patient outcomes, read ChartSpan’s case study on care management at Fairfield Medical Associates, a Rural Health Clinic who saw significant benefits for their rural and underserved patients.