How Health System Leaders Are Scaling Care Management 

The most effective way to reduce hospital admissions, ER visits, and hospital readmissions is to enroll patients in preventive care. But enterprise health systems serve hundreds of thousands of patients across dozens of locations. How can you launch care management at scale, without overwhelming your staff and while ensuring compliance, consistency, and correct billing?

Structured care management programs like Chronic Care Management and Advanced Primary Care Management offer a solution. Medicare care management programs provide clear guidelines for which patients are eligible, how often they should receive care, and what services your health system must provide.

However, you will still need to find the right clinicians, technology and infrastructure to scale a care management program across all of your locations. If these requirements pose a challenge when combined with your other ongoing projects, a dedicated care management partner can help.

In this guide, we'll break down how you and a partner can launch care management across an enterprise health system, determine eligibility at scale, enroll patients, set up inbound and outbound workflows, and address quality measures while running care management.

The Challenges of Launching Care Management for an Enterprise Health System

Enterprise health systems encounter challenges with launching care management that family-owned practices or small clinics don't.

Enterprise systems have existing technology that care management software must successfully integrate with. They also serve large numbers of Medicare patients who need to be evaluated for eligibility, enrolled, and served, and they often already have strict compliance and quality requirements in place.

In 2025, ChartSpan hosted a webinar with Main Line Health on how they successfully launched care management. Main Line's primary care division consists of 42 practices with 299 providers. In addition to compliance and quality experts on staff, Main Line had a pre-existing Epic EHR that any care management partner would need to integrate with.

Through a collaborative rollout process lasting several months, ChartSpan and Main Line were able to:

• Enroll 3,000+ patients in care management
• Field more than 10,000 inbound calls to the 24/7 care line
• Conduct 49,980 proactive outreaches
• Address 7,700+ gaps in care
• Generate more than $965,740 in net profit in the first eleven months*

With ChartSpan's support, Main Line continues to scale their CCM offering across their specialty practices, as well as their primary care ones. They achieved this success by working with ChartSpan to build a robust infrastructure that could successfully determine patient eligibility and continuously enroll patients while actively serving existing patients.

ChartSpan has used similar strategies to launch care management for Inova Health System and Ryan Health. Here is a breakdown of how an enterprise health system can achieve the infrastructure needed to build a scalable, consistent CCM program.

*Results may vary by provider.

Performing Eligibility for Systems with 100,000+ Patients

Smaller practices may be able to manually determine which patients are eligible for care management. But health systems with hundreds of thousands—or even millions—of patients don't have that option.

The most efficient method for tackling care management eligibility is to have dedicated software capable of integrating with your EHR, extracting data, and processing that data to identify patients who meet care management requirements.

Many practices are aware of the basic requirements of care management. For CCM:

• The patient must be a Medicare beneficiary
• The patient must have two or more chronic conditions

For APCM:

• The patient must be a Medicare beneficiary
• The patient can have any number of chronic conditions, but must be stratified into a level accordingly
  • Level 1: 0 or 1 chronic condition
  • Level 2: 2 or more chronic conditions
  • Level 3: 2 or more chronic conditions and Qualified Medicare Beneficiary status

The patient must also have a qualifying encounter with a provider who can participate in care management and must not have a non-qualifying condition set by CMS, like end-stage renal codes or severe behavioral health conditions, such as dementia or schizophrenia.

The need for stratification makes APCM particularly challenging. While EHRs contain a patient's chronic conditions, they do not always contain a patient's QMB status. Even enterprise health systems may not have pre-existing access to the HETS database, which is needed to determine who is a Qualified Medicare Beneficiary.

An effective care management partner will be able to perform this eligibility process for you, including accessing HETS and determining QMB status.

Challenging Eligibility Requirements

Even CCM, which has simpler eligibility, requires data around initiating visits and individual personalization for each practice.

If a patient has not seen their provider within the previous 12 months, they must have an initiating visit before starting Chronic Care Management. Your care management partner should be aware of this requirement and, if they plan to help you with the enrollment process, should limit their eligibility process to patients who have visited their provider in the past 12 months.

APCM is more flexible than CCM with this requirement, allowing patients to enroll if they have seen their provider within the past 36 months. However, you still must check to ensure patients have a recorded visit.

Your practice may also have specialized requirements, such as wanting to leave out certain Medicare Advantage insurances or wanting to exclude patients who are already served by different care management programs. A full-service care management partner can assist you with setting up these requirements before pulling eligibility lists.

Ongoing Enrollment Challenges for Enterprise Health Systems

Eligibility is an ongoing process. Patients continually age into Medicare or become ineligible due to moving into a nursing home full-time, changing practices, or, sadly, passing away.

Your care management partner should regularly remove patients who have become ineligible and perform eligibility checks to determine which new patients are eligible for the program.

Once your partner has created a list of eligible patients, they will need to send it to your practice to review and approve. This ensures your providers maintain general supervision of the eligibility process, as Medicare requires, without burdening your providers with the administrative work of determining eligibility.

Achieving High Enrollment Rates to Keep Your Program Running

Care management requires investments in technology, staffing, and communication infrastructure. Even if your care management partner doesn't charge upfront, the program will eventually require a financial commitment that will only pay off if your care management program achieves high enrollment.

But enrollment is one of the most difficult parts of care management. Medicare patients need to understand what care management is before they can decide if they want to enroll and if they are willing to pay the monthly copays the service often comes with.

An effective care management partner will assist with patient-facing materials, such as:

• Ringless voicemails
• Posters
• Mailers
• Text campaigns
• Email campaigns

When patients hear about the program multiple times, in multiple formats, they have more opportunities to understand what the program is and whether it's right for them.

Once patients have received educational materials about care management, they must be given the opportunity to enroll. This is where enterprise systems face a special challenge, since they may have hundreds of thousands of eligible patients.

Every eligible patient must be offered the chance to enroll in care management. CMS does not allow practices to select some patients for the program and exclude others. Enrollment outreach can be digital or via phone call, but a mixture of both will likely be most effective.

Every enrollment call or digital form must include the following compliance requirements:

• Copays and deductibles may apply
• Patients can unenroll at any time
• Patients can only be enrolled under one provider
• (for APCM) The provider offering care management must serve as the patient's primary point of care

An effective care management partner will also record or document all consents and save the records in case of audits or compliance concerns. ChartSpan saves and archives all patient consents for 10 years and can provide them to your practice upon request.

Technical Infrastructure Requirements When Scaling Care Management

When launching a care management program, you will need sufficient staff and the correct infrastructure to care for patients once they're enrolled. This includes launching an inbound and outbound care line that will not block your existing phone lines, two-way texting, and software to record the minutes spent on care.

Many health systems launch a program believing they can rely on their existing EHR. But if that EHR doesn't include comprehensive time tracking and structured storage for care goals, documentation could go missing, leading to compliance concerns. You will also need to ensure your texting and phone systems can handle a dramatically increased volume of calls or texts.

Patients will reach out to you for regular communication as well as to reach the 24/7 care line. Staffing the care line alone often requires hiring and training new employees, and that doesn't account for the time care managers must spend engaging hundreds or thousands of patients in proactive outreach each month.

Scaling Care Management Without Overwhelming Clinical Staff

The principal challenge of scaling care management across an enterprise health system is staffing. With thousands of patients enrolled in a care management program, you need enough staff to answer patient needs 24/7; to reach out to each enrolled patient monthly; and to provide documented care for every patient.

While enterprise health systems are accustomed to managing large volumes of patients, staff are often far too busy to take on hours of additional care every month, especially after business hours. Every 1,000 patients enrolled in care management can require 654 hours of additional staff time per year.

It's also important to have reliable processes. To bill Chronic Care Management, you must provide every enrolled patient with 20 minutes of care every month and document that care. Otherwise, you could miss out on reimbursements or face Medicare compliance audits.

While Advanced Primary Care Management does not have time requirements, it does require extensive service capabilities. In addition to the care manager, care plans, and 24/7 care plan also required by CCM, APCM adds the requirement to perform quality measure support and discharge management.

Proactive Outreach to Care Management Patients

By partnering with a reliable, experienced care management vendor, you can guarantee that you have enough staff members and established, compliant processes to launch care management.

At ChartSpan, our outbound care management staff are trained to:

• Create a comprehensive care plan with care goals
• Regularly update the care plan and care goals, with the patient's input
• Provide educational materials via email, text or mail
• Connect patients with community resources
• Accurately document care offered and time spent on each patient

This proactive outreach is a cornerstone of care management, ensuring patients can share concerns and take active steps to improve their health before their concerns escalate to an ER visit or hospitalization.

With a care management partner, you will not need to establish care management processes or train staff from scratch. Instead, you can focus on answering any patient questions about the program, reviewing documentation and claims, and providing exceptional in-person care.

However, outbound care is not the only element of care management that must be scaled across a large health system. Inbound care must be scaled as well, with a continually staffed 24/7 care line available to hundreds of thousands of Medicare patients.

Individualized Care, on a Large Scale

Chronic Care Management and Advanced Primary Care Management include a fully staffed care line available to patients 24/7, including on national holidays, nights and weekends. This allows the patient to receive quick, responsive care, even when their provider's office is closed.

Once patients know a 24/7 care line is available, the number of patients calling for assistance will increase. Across a 1,000-patient APCM cohort in one year, ChartSpan provided:

• 733 instances of nurse triage for concerning symptoms
• 649 medication refills
• 625 assists with scheduling appointments

Expanding these statistics to a larger health system with 100,000 patients, we see that there could be 73,300 instances of nurse triage, 64,900 medication refills, and 62,500 assists with scheduling appointments in one year. While these numbers are not exact, they give an idea of how many patient inbound needs there could be, and yet each of them is critically important.

For example, one Main Line patient faced delays in receiving his cancer medication. His care management team followed up with the pharmacy and his provider to ensure he received the medication. He shared how much the support meant to him and turned to ChartSpan again when he needed help scheduling a CT scan.

Any patient could benefit from 24/7 access to care, but offering tens of thousands of new assists is overwhelming for most health systems. A care management partner already has the staff and the phone technology to manage these demands.

Addressing Quality Measures at Scale

Unlike smaller practices, most major health systems have an effective quality program in place, with dedicated professionals to oversee quality measures like vaccinations and screenings as well as outcomes like hospital admissions and ER utilization.

Care management can support existing quality programs, like MIPS, MIPS Value Pathways, ACOs and Alternative Payment Models. However, your quality experts will either need to create a plan from scratch or partner with care management experts to weave care management quality measures into your existing initiatives, instead of attempting to run two separate quality programs.

One of care management's greatest strengths is its ability to monitor quality measures like vaccinations, Social Determinants of Health, and medication adherence on an ongoing basis. In one year, ChartSpan care managers were able to perform more than 4,000 quality assessments for 1,000 APCM patients, including:

• 2,678 condition awareness assessments
• 818 activities of daily living assessments
• 391 medication adherence screenings
• 238 social determinant of health screenings

If patients showed gaps in any of these areas, care managers could assist them by adjusting their care goals, providing educational materials, or referring patients back to their provider. For social determinants of health needs, care managers could also connect patients to community resources to assist with transportation, food, housing, clothing, and utilities.

Another health system, Med First, embraced CCM for roughly 1,900 patients and saw:

• 950 medication refill assists
• 859 referrals to nurse triage line
• 467 SDOH assists
• 437 appointment assists

Large health systems like Med First serve tens of thousands of Medicare patients. Routine screenings and assistance with refills, appointments, or community resources aren't the best use of providers' limited face-to-face time with patients.

Because care managers reach out on a monthly basis, they have multiple opportunities to perform screenings and identify routine needs like medication refills, appointment scheduling, or assistance with groceries and transportation. By meeting these needs, care managers can reduce patients' cost of care. ChartSpan achieved a $2,457 per patient reduction in annual costs for CCM patients, helping practices and health systems achieve their value-based care goals.

Support with Specific Gaps in Care

Care managers can also address gaps in care around specific quality programs. For example, MIPS and many MVPs require patients to regularly report their A1C scores, so there is a record of whether the patients' score is below a certain threshold (9% for 2026).

Care managers can record patients' A1C scores in between appointments to see if they're on the right path to hit the quality measure goal. They can also help patients interpret what their A1C scores mean. One Main Line patient reached out to their care manager because they found their lab results in MyChart confusing and weren't sure whether their A1C level was healthy.

Their care manager was able to review the results with the patient and share the good news that their A1C had dropped 7 points, into a healthy range. The patient was relieved that their scores had improved and their lifestyle changes were working.

Care managers can also prompt patients to pursue vaccinations and screenings they've been putting off. Some of the most common gaps in care addressed by care managers include:

Adult vaccinations:

• Influenza
• Pneumococcal pneumonia
• Herpes zoster (shingles)
• Tetanus, diphtheria and pertussis (Tdap)
• Hepatitis B

• Depression screening
• Cognitive screening
• Breast cancer screening
• Colorectal cancer screening

When care managers refer patients back to their provider for preventive services or follow-up, patients reduce their risk of ER visits and hospitalizations. Practices also increase the likelihood that those patients will be attributed to them for quality programs and count toward their quality scores.

Impact of Discharge Management on Patient Care

One of the most difficult value-based care requirements is preventing hospital readmission. The first 30 days after patients transition from an inpatient care setting to their home can prove difficult. Patients might struggle to understand or adjust to new care instructions, and new medications or Durable Medical Equipment might be difficult to access.

Patients may also lack transportation to bring them to follow-up appointments, grocery stores or pharmacies. All of these complications increase patients' risk of being readmitted to the hospital.

Discharge management, a crucial element of APCM, offers patients support as soon as they're discharged from the hospital. Care managers follow up within 48 hours of discharge to see how the patient is doing, to discuss any medication, DME, or SDOH needs they may have, and to attempt to schedule a follow-up appointment with the patient's provider.

APCM care managers can walk patients through their detailed care plan, set up medication or meal delivery, arrange transportation, and reach out to the provider directly to set up an appointment. ChartSpan's discharge management team follows up at 7-, 14- and 30-day intervals to ensure the patient is still doing well, and the patient can reach out at any time, 24/7. In 2025, 89% of patients who participated in discharge management through ChartSpan's APCM program were able to avoid hospital readmission for 30 days.

Managing discharge can be overwhelming for enterprise practices with large numbers of patients. APCM streamlines the process while improving quality measures and patients' quality of life.

Scaling Care Management Without Overwhelming Your Health System

Enterprise health systems have experience meeting the needs of their ACOs or value-based care programs and often already run case management programs for high-complexity patients. But when your system must serve hundreds of thousands of Medicare beneficiaries, it can be difficult to launch a care management program to serve rising- or lower-risk patients.

While Chronic Care Management focuses only on patients with two or more chronic conditions, Advanced Primary Care Management is available to all Medicare patients, demanding that you perform eligibility, enrollment, inbound and outbound care, and quality assessments on a massive scale.

An established care management partner can smooth out the bumps of this process, helping you accurately perform eligibility, meet your enrollment goals, serve all of the patients you enroll, and improve your quality performance.