The Infrastructure You Need for Care Management Services

Care management services can reduce hospitalizations, ER visits, and hospital readmissions by offering patients preventive care between office visits. But regardless of the care management program you choose, you will need a strong infrastructure with sufficient staff members, technology, and processes to make your program effective and compliant.

This is especially true for one of the most popular Medicare care management services, Chronic Care Management (CCM). Designed to provide preventive care to Medicare beneficiaries with two or more chronic conditions, CCM requires the ability to continuously identify and enroll eligible patients, to staff a 24/7 care line, and to ensure every patient receives 20 minutes of coordinated, documented care each month.

Starting in 2025, CMS now reimburses for another care management program, Advanced Primary Care Management (APCM). APCM includes many of the same features as CCM but has no time requirements and is available to all Medicare beneficiaries. APCM also adds more infrastructure requirements, including the ability to identify Qualified Medicare beneficiaries, address gaps in care for the patient population, and track patient hospital or ER discharges.

Launching either CCM or APCM can improve your patients’ long-term health outcomes and generate revenue for your practice. But first, you need to ensure your practice has the infrastructure and staffing to manage these complex programs or that you have a partner who does. Let’s explore the infrastructure you need to successfully launch care management services.

Infrastructure Needed for Both CCM and APCM Services

Chronic Care Management and Advanced Primary Care Management require the ability to constantly determine patient eligibility, enroll patients, staff a 24/7 care line, and provide enough staff to manage care plans, prescription refills, appointment scheduling, screenings, and quality measures. Here’s some of the infrastructure you’ll need in place to launch a care management program.

Eligibility and Enrollment Processes

Both CCM and APCM require software to determine which patients are eligible for the program and staff to educate those patients and request their consent. Many care management programs lack the resources to continually enroll new patients. This leads to the average health system only enrolling 7% of their eligible Medicare population, according to Lexis Nexis claims data.

To determine whether patients are eligible for care management, you must quickly evaluate their Medicare enrollment status and ensure they aren’t ineligible because of factors like living in a nursing home full-time or having end-stage kidney disease.

Patients will continually churn in to care management programs, due to their health status or becoming eligible for Medicare, and churn out due to transitioning to a nursing home, simply deciding they don’t wish to participate, or, sadly, passing away. This makes determining patient eligibility a time-consuming process, requiring advanced parsing software.

Enrollment comes with its own challenges. Staff must educate patients on what care management is, ideally using a variety of materials, such as posters, brochures, mailers, text messages, and phone calls. Enrollment staff must also explicitly lay out CMS’s care management compliance requirements, including:

There may be a copay and deductibles do apply
Patients can unenroll from the program at any time, for any reason
Patients can only enroll in care management under one provider

Advanced Primary Care Management does not require a copay or deductible for Qualified Medicare Beneficiaries with two or more chronic conditions and also requires the provider to assume primary care responsibilities for the patient. All patients need to hear these compliance requirements before they can enroll in CCM or APCM.

To address these highly specific needs, ChartSpan uses trained enrollment specialists. If your practice lacks the staff and software to continually perform eligibility and enrollment, partnering with a care management organization who has a built-in process and trained staff can help.

24/7 Inbound Care Line

Advanced Primary Care Management and Chronic Care Management both require a phone line that patients can access 24/7. The staff for this phone line should be able to address common concerns, such as minor symptoms, appointment scheduling, or prescription refills, as well as more serious symptoms.

ChartSpan’s 24/7 phone and text line includes a nurse triage line, staffed by RNs who use Schmitt-Thompson triage protocols to evaluate concerning symptoms. The nurses refer to the protocols to determine whether the patient needs to visit the ER, go to urgent care, or make an appointment with their provider.

95% of patients who are transferred to the triage line follow the nurse’s recommendations, and 70% of patients who originally intended to self-refer to the ER are directed to a more appropriate care setting. If you plan to run a 24/7 care line internally, you need to ensure you have both clinicians and nurses who are willing to work irregular hours, including nights, early mornings and weekends, and who are trained to address diverse needs, such as triage.

Outbound Comprehensive Care Management

The 24/7 care line is a critical component of both Advanced Primary Care Management and Chronic Care Management. However, both programs also emphasize preventive care, which requires care managers to proactively reach out to patients.

In addition to enough clinicians to manage the inbound care line, your practice will need enough staff to perform outreach to patients and spend 20 minutes of care each month (for Chronic Care Management) or on a regular cadence as needed (for Advanced Primary Care Management.) These care managers will help patients create and update comprehensive care plans with personalized care goals.

They’ll also be responsible for performing screenings, such as cognitive, Activities of Daily Living, and Durable Medical Equipment assessments, to ensure health problems are identified before they worsen. Additionally, care managers can remind patients about the need for preventive care, such as cancer screenings and vaccinations, and can address Social Determinant of Health needs, such as housing, nutrition, utilities and transportation.

By directing patients to resources in their local area, care managers can ensure patients have healthy food, a safe place to live, and transportation to upcoming medical appointments.

These preventive care measures help prevent patients’ conditions from worsening, lowering their risk of hospital or ER visits and hospital readmissions. According to Medicare claims data, ChartSpan care management has been able to reduce enrolled patient hospitalization costs by 36% and ED costs by 19%.

To achieve the best results from preventive care programs, you will need well-trained care managers who have access to software to document their care plans and all care management interactions.

Infrastructure Needed for Advanced Primary Care Management

While Advanced Primary Care Management removes the need for spending 20 minutes per month on each patient, it comes with other requirements that necessitate advanced infrastructure. Practices interested in APCM will need to ensure they have the resources to:

Successfully stratify patients into levels, including identifying QMBs
Receive notifications for and respond to hospital discharges
Perform two-way digital communications
Engage in population health analytics

These requirements make APCM more technologically demanding than CCM. Because of these demands, many practices choose to launch Chronic Care Management before attempting Advanced Primary Care Management. However, whether you’re transitioning to APCM or building a program from scratch, building infrastructure before launching the program is essential.

Stratification Into Levels and QMB Identification

While APCM is open to all Medicare patients, it requires practices to stratify those patients into levels.

Level 1: Medicare patients with one or fewer chronic conditions
Level 2: Medicare patients with two or more chronic conditions
Level 3: Qualified Medicare Beneficiaries (QMBs) with two or more chronic conditions

Level 3 patients will not have a copay and deductible and will likely require more extensive support than Level 1 and 2, especially with Social Determinant of Health needs. To determine whether a patient is a QMB or not, you will need access to the HETS database or a partner who has access to the HETS database.

Since QMBs never have cost-sharing responsibilities, it’s critical to correctly identify Level 3 patients before you attempt to enroll them in care management. Identifying Level 1 and 2 patients also allows you to adjust the outbound care provided so it matches patients’ current health needs.

Discharge management

Advanced Primary Care Management requires practices to perform discharge management for their enrolled patients. Care managers must follow up when patients are discharged from the hospital or another inpatient setting, ideally within 48 hours, to schedule an in-person appointment, check on the patient’s health, and help the patient navigate any new transportation, medication, Durable Medical Equipment, or Social Determinant of Health needs.

To successfully carry out discharge management, your practice will need access to admission and discharge notifications from a wide network of hospitals. You’ll also require care managers who have sufficient time to reach out to the patient. These care managers need to be prepared to schedule appointments, explain discharge instructions, and direct the patient to any community resources they may need.

Two-way digital communications

Chronic Care Management and Advanced Primary Care Management both require offering patients multiple communication options. However, Advanced Primary Care Management specifies that digital forms of outreach must be used. This could include a patient portal, two-way email, two-way texting, or digital surveys.

For example, ChartSpan has technology that allows care managers to send HIPAA-compliant health surveys via text message. Patients who have opted into text can quickly complete a survey on hypertension, A1C levels, adult vaccinations, diabetic eye exams, and other quality measures, and care managers can review their answers to identify gaps in care that may need to be addressed.

Population health analytics

APCM also requires the ability to perform population health analytics across all enrolled patients. Many practices don’t have the ability to pull records from outside of their health system. But for an ideal APCM program, clinicians would have access to records from multiple providers, pharmacies, state and national databases, giving them detailed records of all the care patients have received.

This insight allows care managers to determine which gaps in care most need to be addressed and would have the greatest impact on population health. After a quality team identifies a large number of open care gaps, they can notify clinicians to address those care gaps and refer patients back to their provider, where needed. This allows practices to close care gaps and improve their quality scores.

How a Partner Can Assist with the Infrastructure for Care Management Services

If your practice is concerned about the investment in technology, staff and processes required to run an in-house care management program, partnering with a care management organization with pre-built infrastructure can help. ChartSpan has already invested over $145 million into APCM and CCM infrastructure and manages nearly one million patient encounters per month.

This experience allows ChartSpan to save clinical staff an average of 65 hours of time for every 100 care management patients. ChartSpan also maintains close ties with practices, working with providers and clinical staff to introduce patients to the program and notifying the practice when a patient needs additional care.

This personalized care leads to better patient health outcomes, with hospital readmission rates reduced by 52% according to ChartSpan claims data. Having access to care management programs 24/7 empowers patients to proactively manage their health while staying engaged with their practice.

If you’d like to learn more about putting the right infrastructure in place to launch a care management program, whether in-house or with a partner, you can book an appointment to speak with one of our experts here.