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How Many Touches = Engagement?



The road to value-based medicine has highlighted the need for patient engagement in healthcare's "dark space," that time between provider visits.


The 99490 code promised to pay Fee For Service providers to give Chronic Care Management services to their patients. The code requires a minimum of 20 minutes per month (with alternative options for complex issues), but the results were mixed. To follow the letter of the code, it would take closer to 40 minutes for the first few months to put together the Comprehensive Care Plan. Many CCM companies just take the sponsoring providers' care plans and focus their time on a single phone call per month.

At CareSync, hours were spent putting together Comprehensive Care Plans, reconciling medication lists, and interacting not only with patients, but also their families, but it resulted in a failed model due to the time and labor required to do so. Still, many lives and a lot of money was saved. The monthly phone call often found members in distress, not sure whether to go to the ER or not. The team followed the providers' protocols and often organized transportation to an ER, helped the family make an appointment with the doctor the next morning, or arranged services that solved serious Social Determinants of Health (SDoH) issues, like arranging for meals or ramps in the home.


Is one call per month enough? Twelve contacts per year? I propose that it is not enough for many of the important issues facing chronically ill patients:

  • Social Determinants. We know that 80% of health issues can be attributed to Social Determinants of Health (SDoH). It takes a relationship between a caregiver and patient to build trust and understand the environment to get to these issues.

  • Medication Adherence. What if patients could say daily or weekly if they took their medications as prescribed? A monthly call can capture updated medication lists, but isn't frequent enough to catch missed doses or intermittent side effects.

  • Trends. Twelve touches per year isn't enough to show trends. More frequent interaction can help uncover depression, early stages of dementia and Alzheimer's, inactivity, and more.

How often do you think patients interact with care coordination teams?

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