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The Provider’s Guide to Patient Engagement: Strategies to Turn Activation into ROI

Patient engagement is central to every organization’s clinical and financial performance. Rising rates of chronic disease, increasing multimorbidity, and the demands of long-term condition management mean that meaningful engagement is essential.

At the same time, value-based care (VBC) and risk-bearing contracts require health systems to deliver consistent outcomes, manage costs proactively, and demonstrate measurable improvements in both patient experience and quality.

For healthcare leaders and care teams, this creates a familiar tension: you are responsible for improving outcomes and reducing avoidable utilization while operating with limited resources, growing administrative burdens, and patients whose needs are more complex than ever.

Engagement is one of the few levers that influences all sides of this equation. Engaged patients are more likely to adhere to treatment, participate in shared decision-making, follow care plans, and report higher satisfaction. These behaviors translate into better outcomes and lower avoidable utilization.

The opposite is also true. Disengagement carries very real clinical and financial consequences. More than 40% of patients are at risk when they misunderstand, forget, or ignore care recommendations, often leading to complications and preventable acute events.

For CFOs, disengagement increases risk exposure, suppresses revenue tied to reimbursable care management programs, and jeopardizes performance in value-based contracts. For care teams, disengagement means more time spent managing crises, correcting misunderstandings, and addressing preventable issues that fuel inefficiency and burnout.

And yet, effective engagement remains elusive for many organizations. The challenge is that true engagement goes far beyond portal logins, reminder messages, or occasional outreach. It requires activating patients by helping them build the motivation, confidence, and cohesion with their care team needed to meaningfully participate in their health.

Evidence-based strategies, paired with support from dedicated care-management teams like ChartSpan, can make engagement achievable even in resource-constrained settings.

What is patient engagement?

Patient engagement refers to how informed, involved, and empowered patients are in managing their health and making care decisions. It is grounded in the Institute of Medicine’s (IOM) definition of patient-centered care: “care that respects and responds to patients’ preferences, needs, and values and ensures that patients’ values guide all clinical decisions."

For your healthcare organization, engagement isn’t just about whether patients show up or log into a portal. It’s about whether they understand their condition, feel supported, and have the confidence and tools they need to follow through. Strong engagement reflects two things working together: patients who are ready to participate and a system that makes that participation realistic and achievable.

Patients are not passive recipients of care but are essential stakeholders in quality, efficiency, and service delivery. Strong engagement reduces hospitalizations, improves care effectiveness, increases patient satisfaction, and enhances responsiveness across the system. 

For CFOs and operational leaders, that reframes engagement entirely. When patients are true stakeholders, engagement becomes core infrastructure–a system-level investment that influences outcomes, costs, and long-term sustainability.

The activated patient 

Engagement is the starting point, but activation is what ultimately drives behavior change. An activated patient doesn’t just receive information; they know what it means for their life, feel motivated to take action, and believe they can manage their health effectively between visits.

Research on treatment adherence highlights four core components that influence activation:

• Motivation — understanding why engagement matters.
• Cohesion — feeling aligned and supported by their care team.
• Commitment — willingness to follow through on agreed-upon steps.
• Empowerment — confidence in their ability to act.

If your engagement strategy doesn’t intentionally build these four elements, it often misses the mark. Patients may receive education and reminders, but still feel unsure, unprepared, or overwhelmed, resulting in little to no change in behavior.

The role of patient-centered communication in engagement

Patient-centered communication (PCC) is the primary driver of patient engagement. When clinicians and care managers communicate in ways that draw out patients’ perspectives, build trust, and make information clear and actionable, patients are far more likely to adhere to treatment, participate in shared decision-making, and stay engaged over time. 

Effective PCC consistently includes:

• Inviting patients to share their beliefs, concerns, and preferences.
• Exploring the broader context of their lives—mental health, social support, daily barriers.
• Building trust and mutual respect.
• Explaining diagnoses and treatment options in plain, understandable language.
• Encouraging questions, dialogue, and shared decisions.
• Aligning care plans with evidence and with what is realistic for the patient.

These communication behaviors meaningfully influence adherence, outcomes, patient experience, and even cost trends. They are foundational to any engagement or care-management strategy, especially for organizations navigating risk-bearing models or treating high-need populations.

The cost of disengagement 

Disengagement appears quickly in clinical outcomes, operational performance, and financial stability. When patients aren’t informed, motivated, or supported to participate in their care, the downstream impact is predictable, measurable, and costly.

Clinical and safety costs

One of the clearest risks is misunderstanding. When patients misunderstand, forget, or ignore care recommendations, they are placed at significant risk of complications or preventable acute events.

Lower engagement is also consistently linked with:

• Poorer control of chronic conditions
• Higher levels of depression and anxiety
• Increased emergency department visits and avoidable hospitalizations

When patients aren’t activated, they’re less likely to follow through on care plans, which increases the likelihood of complications and avoidable acute care episodes.

Economic and operational costs

Nonadherence and disengagement carry a substantial economic burden for health systems. These costs show up in:

• Higher avoidable utilization
• Greater variability in outcomes
• Missed opportunities for reimbursable care management programs
• Lower performance in value-based contracts

Effective engagement can improve treatment adherence, patient satisfaction, and overall care quality, but many organizations still lack consistent systems for measuring the full clinical and financial impact of these efforts. 

For under-resourced clinics and safety-net providers, disengagement compounds existing challenges. It increases staff workload, drives inefficiencies, and makes it even harder to meet quality metrics tied to reimbursement.

10 effective patient engagement strategies 

Improving engagement isn’t about volume of outreach. It’s about creating systems that build understanding, motivation, and trust, which in turn drive activation and measurable clinical and financial outcomes.

1. Make patient-centered communication the default

Challenge:

Clinical encounters are often time-pressured, jargon-heavy, and clinician-directed. Patients leave visits unsure what was decided or why, and that uncertainty undermines adherence and long-term engagement.

Patient-centered communication (PCC) is associated with higher engagement, better satisfaction, improved service quality perception, and stronger health-related quality of life. Evidence also suggests that when patients and clinicians share decisions and information effectively, there are fewer unnecessary diagnostic tests and referrals, contributing to more efficient care delivery

Solution

For care teams:

• Start every encounter by eliciting the patient’s goals and concerns.
• Use teach-back to confirm understanding.
• Invite questions and preferences rather than assuming alignment.
• Share decisions, not just recommendations.
• Use EHR prompts or care-management scripts to make PCC behaviors consistent.

For leadership/CFOs:

• Treat PCC as a strategic lever, not a soft-skills initiative.
• Embed communication-related metrics in quality dashboards and value-based reporting.
• Train staff systematically and link PCC to performance improvement efforts.
• Position PCC as part of your cost-reduction and risk-mitigation strategy.

2. Use care management programs to sustain patient engagement between visits

Challenge:

Most patient engagement collapses between appointments, not during them. Without a structured program, like Chronic Care Management (CCM) or Advanced Primary Care Management (APCM), there is no reliable, systematic way to monitor symptoms, reinforce care plans, identify barriers early, or provide continuous support. Engagement becomes episodic, reactive, and dependent on the patient initiating contact, which leads to preventable complications and missed opportunities in value-based care.

Solution:

CCM and APCM programs create predictable touchpoints that keep patients connected and supported. Care managers can review goals, reinforce care plans, assess changes in symptoms, and identify Social Determinants of Health (SDOH) barriers before they derail progress. These recurring interactions sustain motivation, strengthen adherence, and improve accountability—exactly the conditions needed to maintain activation outside the clinic.

For leadership and CFOs, CCM and APCM also create financial sustainability around engagement. These programs generate reimbursable revenue tied to ongoing patient support, helping organizations invest in proactive care while improving performance in value-based arrangements.

3. Design care management for patient activation

Challenge:

Many patient engagement programs treat outreach volume—calls, messages, reminders—as a proxy for success. But frequency alone doesn’t activate patients. Activation requires addressing the psychological and relational factors that drive follow-through. Motivation, cohesion, commitment, and empowerment strengthen activation and adherence. Patients with higher engagement levels also show meaningful improvements in anxiety and overall quality of life.

Solution:

Restructure care-management workflows around the four activation drivers:

• Motivation: Connect care plans to what matters personally (“play with grandkids more often,” not just “reduce A1c”).
• Cohesion: Ensure consistent messaging across providers and care managers.
• Commitment: Co-create specific action steps and let patients set priorities.
• Empowerment: Offer tools, skills training, and positive reinforcement; acknowledge small wins.

4. Address Social Determinants of Health and low-income barriers

Challenge:

Low-income and high-risk patients often face structural barriers, like transportation issues, food insecurity, unstable housing, and medication inaccessibility, that overshadow medical priorities. Traditional engagement methods, such as reminders or education, have limited impact when the patient cannot meet basic health needs or logistical requirements.

Solution: 

For care teams: 

• Screen for SDOH consistently during CCM/APCM or routine care.
• Integrate referrals to community and social services directly into care plans.
• Tailor treatment recommendations to what is realistically achievable in a patient’s daily context.

For leadership/CFOs:

• View SDOH interventions as risk-mitigation investments, not add-ons.
• Allocate resources or partner with care management programs that provide SDOH support.
• Track SDOH-related barriers as predictors of utilization and value-based performance.

5. Build trust and relational continuity between visits

Challenge:

Patients often feel like they’re interacting with a rotating cast of clinicians and staff. Conflicting advice, rushed encounters, or lack of follow-up erodes trust, making it less likely that patients will share barriers, ask questions, or follow care plans.

Trust and strong patient-centered communication can increase participation in decision-making and adherence to treatment. Engagement interventions tailored to patient needs also improve follow-through, especially for conditions like depression.

Solution:

For care teams: 

• Assign consistent care managers whenever possible.
• Document with narrative-style notes so every staff member “picks up the story,” not restarts it.
• Use proactive check-ins to maintain continuity between appointments.
• Provide 24/7 access points that feel supportive, not rushed or punitive (care management programs like APCM and CCM can assist with this through a 24/7 care line).
• Offer culturally and linguistically appropriate communication.

For leadership/CFOs:

• Track communication and trust-related measures (e.g., CAHPS items).
• Use these as early indicators of adherence, utilization risk, and cost trends.

6. Make care plans visible, accessible, and actionable

Challenge:

Patients forget much of what they hear in visits, and care plans are often buried in clinical notes or written in technical language that is difficult to follow. Providing clear, revisitable information significantly improves engagement, self-management, and activation.

Solution:

• Deliver concise, written or digital care plans that outline:
  • What to do
  • What to monitor
  • When to call
  • What success looks like
• Provide condition-specific education in plain language.
• Reinforce care plans during follow-up calls or texts.

7. Ensure 24/7 access to clinical support

Challenge:

Patients often struggle with symptoms or questions outside business hours. Without real-time guidance, they may default to the ED, skip medication adjustments, or delay care. Limited access erodes trust and confidence in self-management.

Solution:

Offering 24/7 access to clinical guidance gives patients a safety net, reduces unnecessary utilization, and reinforces activation. A staffed care line can help patients understand whether to manage symptoms at home, schedule a next-day visit, or seek emergency care. This strengthens decision-making, reduces avoidable ED visits, and ensures patients never feel “on their own.”

8. Offer community and social support

Challenge:

Even when basic needs are met, many patients struggle with isolation, limited motivation, or lack of accountability. Social support plays a critical role in sustaining healthy behaviors, reducing stress, and improving adherence, yet it is often missing from traditional medical care.

Solution:

Connecting patients with community resources (exercise groups, cooking classes, chronic disease support programs, peer groups, mental health services) provides the encouragement and accountability needed to follow through on care plans. These supports extend engagement into the patient’s everyday environment, strengthening activation and helping patients maintain momentum between clinical interactions.

9. Implement digital tools to scale personalized engagement

Challenge:

Digital tools can help personalize communication, reinforce understanding, and support follow-through by delivering the right information at the right time. Engagement improves when care is tailored to patient needs. Offering multiple ways to participate (text, phone, web, app) is one way to make it easier for patients to stay connected, respond to outreach, and follow through on care plans.

Solution:

For care teams: 

Offer patients multiple communication options:

• Two-way texting
• Phone outreach
• Portal messaging
• Email
• Digital surveys or brief educational content

Where available, use analytics or AI-supported insights to identify risk patterns, gaps in follow-through, or opportunities for timely outreach.

Learn more: The Role of Artificial Intelligence (AI) in Chronic Disease Management

For leadership/CFOs:

• Invest in HIPAA-compliant engagement platforms that integrate with the EHR.
• Track financial impact through no-show reduction, improved AWV completion, better chronic disease control, and reduced avoidable utilization.

10. Partner with a care management team to extend capacity and sustain engagement

Challenge:

Even when organizations understand what drives engagement, many cannot operationalize this level of support with in-clinic staff alone. Staffing shortages, competing priorities, and episodic workflows limit the ability to maintain high-frequency, personalized patient contact.

Solution:

Partnering with a dedicated care management team can allow your organization to extend its reach, support patients between visits, and reinforce the behaviors that activate and engage patients—all without adding significant workload to clinical staff.

A care management partner like ChartSpan functions as an extension of the care team, providing monthly CCM and APCM outreach, personalized care plans, and continuous education that keep patients aligned with their treatment goals. 

At Arthritis Medical Clinic, partnering with ChartSpan helped the practice reach 83% CCM patient engagement within just 60 days, showing how dependable, relationship-based outreach can quickly draw patients into more active participation.

Our care managers address barriers as they arise, offer 24/7 clinical support, and maintain consistent, relationship-based communication that builds trust and strengthens adherence. With multimodal engagement options such as two-way texting, phone outreach, and digital surveys, patients can participate in the ways that feel most accessible, while providers gain the benefit of structured, evidence-aligned engagement delivered at scale.

Measuring the ROI of patient engagement strategies

Improving patient engagement creates value across clinical, financial, and operational domains, but capturing that value requires a measurement approach that goes beyond any single metric. While engagement consistently improves outcomes, satisfaction, and service quality, ROI is complex and is best evaluated using a coherent set of measures.

This requires a measurement framework that reflects the full impact of engagement rather than relying solely on downstream utilization or short-term financial signals.

Effective measurement spans four domains that create a complete picture of whether engagement strategies are driving value and where additional support or investment is needed.

Clinical outcomes

These reflect whether engagement is translating into better health and fewer preventable events.

Examples include:

• Improvements in chronic disease metrics (A1c, blood pressure, lipids)
• Reduced hospitalizations and readmissions
• Lower emergency department utilization

Better engagement strengthens adherence and self-management, which directly drives improvements in these measures.

Engagement and experience metrics

These metrics reveal whether patients are interacting with their care teams in meaningful ways and whether they feel supported.

Examples include:

• Participation in touchpoints in CCM/APCM
• Portal or text response rates
• Patient surveys and digital form completion
• Communication- and trust-related experience scores, which are directly linked to engagement and adherence

These indicators act as early signals of future clinical and financial trends.

Behavioral and mental health outcomes

Engagement is behavioral, emotional, and psychological, and highly engaged patients experience improvements in anxiety and health-related quality of life.

Examples include:

• Treatment adherence (medication refill rates, appointment follow-through, referral completion)
• PHQ-9 and GAD-7 trends for populations receiving regular outreach
• Behavior-change indicators, such as documented lifestyle modifications

These measures reflect whether patients feel confident, supported, and empowered to manage their conditions.

Financial and operational metrics

These outcomes matter most to CFOs and demonstrate how engagement translates into sustainability.

Examples include:

• Revenue generated from CCM, APCM, and AWV billing
• Avoided costs from reduced ED visits and readmissions
• Improvements in staff efficiency (fewer inbound crisis calls, more planned care, reduced administrative burden)
• Performance in value-based contracts, shared savings programs, and quality incentives

These measures show the full financial picture—not just cost reduction, but revenue generation and improved predictability.

Effectively increase patient engagement with ChartSpan

Through CCM and APCM programs, ChartSpan delivers the consistent, personalized support patients need to stay engaged between visits. 

Monthly calls, personalized care plans, and ongoing education, ChartSpan helps patients connect care to what matters most in their daily lives, feel aligned and supported by their care team, commit to feasible action steps, and build the confidence needed to manage their health between appointments. 

Patient-centered communication in every interaction

Our outreach model embeds patient-centered communication into every interaction. Care managers lead structured, conversational calls that elicit patient goals and concerns, invite questions, reinforce care plans in clear language, and document patient preferences and barriers. This level of clarity and consistency strengthens understanding without extending appointment time for in-clinic providers.

24/7 clinical support and trusted continuity

Patients have access to a 24/7 clinical support line and benefit from clear escalation pathways back to the practice. This helps patients feel known, supported, and safe reaching out, reducing unnecessary visits while ensuring emerging issues are addressed before they escalate.

Support for low-income patients with multiple conditions   

Through APCM, ChartSpan provides targeted support for low-income patients with multiple conditions. Care managers assist with food, transportation, housing, and medication access; help patients schedule and prepare for appointments; and troubleshoot challenges that often derail follow-through. 

Multi-modal engagement

ChartSpan also offers a scalable, multi-modal engagement infrastructure. Two-way texting, phone outreach, digital surveys, and integration with practice workflows allow patients to interact in the ways that feel most convenient and accessible to them. Our care team reinforces understanding through clear, actionable care plans and condition-specific educational materials, revisiting guidance during regular outreach to ensure patients remember and act on what they’ve learned. 

Clinical, operational, and financial impact

For healthcare leaders, this partnership improves value-based performance, enhances chronic disease outcomes, increases revenue from care management programs, reduces organizational risk, and alleviates staff workload and burnout. 

ChartSpan transforms engagement from a resource-intensive challenge into a scalable engine for clinical and financial performance.

Talk to an expert to learn how ChartSpan can help your organization strengthen patient engagement, improve outcomes, and create a more sustainable care model.

You may also like: 

• How an Advanced Primary Care Management Program Can Improve Your Quality Performance
• The Hidden Costs of In-House Chronic Care Management
• Patient-Centered Care Explained with 5 Examples