Drew Kearney, JD

Getting real benefits from care coordination efforts depends on how well physician practices manage patients in between face-to-face care-

. Having the technology to supplement patient relationships and navigation is important, but 

Beyond that, capitalizing on value-based payment opportunities is becoming more and more critical to protecting your margins. Meeting the requirements to bill Medicare and other payers for providing care to patients in their homes can pay off significantly in better care and new revenues, but may require time that your staff doesn’t have. Hiring nurses, enrolling patients, and managing remote care is time consuming and hard to make work at an individual practice level.

That’s why scalable care management models are gaining traction. These allow nurse care managers to augment practice resources, helping ensure patients’ health and wellness is optimized between office visits, especially for those managing multiple chronic conditions. Through monthly telephone touch points, nurse managers can connect with patients about their health concerns, conduct health assessments, deliver education, and proactively intervene when needed. As an added benefit, nurses also build a strong, trusting relationship with patients. The right model can combine this personalized care management with strong technology that fully integrates with the practice’s EMR. And by providing services to multiple practices, they can deliver financial benefits to practices despite limited reimbursement. 

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Yet some physicians are understandably concerned about whether a third-party model can work for them. Here are the three concerns we hear most often:  

Just because remote care happens over the phone doesn’t mean nurses or patients aren’t fully engaged. Human interactions with healthcare professionals on a regular basis-whether in person or over the phone-have been shown to improve health, 

, and preventative care. The key is ongoing, personalized counseling, education, and better explanations of benefits and risks. 

Patients have a direct clinical contact they can call or text at any time, knowing their physician will also be notified and their chart updated with each call. These connections can improve the person’s day-to-day mental well-being and physical health, contributing to a loyal relationship with the physician practice and fewer calls to physician staff. 

2. Handing over check-ins between visits cedes too much provider control

This is perhaps the biggest mental hurdle for physicians to overcome, and it’s understandable that they don’t want to lose control over their patients’ wellbeing. But, as patient demands for access to healthcare increase, and chronic care becomes more complex, physician offices aren’t sufficiently equipped to connect with patients in the thousands of hours they aren’t getting care in a facility. Nearly 75 per cent of adults want continuous interaction with their healthcare provider between appointments and believe their provider should be doing more to support health and wellbeing, even when they aren't sick. 

That’s one of the greatest benefits remote care management has to offer-meeting consumer demands without stretching physician practices too far. Research shows that there’s power in remote care nurses and the 

Patients are happy to hear from their physician through these nurses

 and know that they can count on them to guide them through their care process. 

3. Implementing remote care will be too disruptive to existing physician workflow

 decision-making data is integrated into the workflow, clinicians tend to use it

, but most don’t have this luxury. In an optimized remote care model, however, 

existing workflows are enhanced rather than disrupted

 by integrating fully with the practices’ EMR. And, working real-time in a patient’s EMR enables the nurse care manager to have direct communication with the physician and vice versa.

While technology can enhance efficiency, it isn’t sufficient unless it’s paired with the human connections that improve patient health and retention over the long term. The right combination of technology and people can help patients make lifestyle changes that improve their health while driving new CCM or other revenue-without requiring practices to take on the burden of staffing or managing yet another program. 

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Taking care of patients beyond the office setting is critical to optimizing patient’s health and satisfaction. However, delivering such care without having to take on yet one more burden that is insufficiently reimbursed and without losing control of patient care has prevented many practices from pursuing remote care management.

A scalable model that combines the best of technology and people, forging lasting connections between experienced nurses and patients, can benefit both practices and patients. Practices gain by having additional resources who can monitor, care, educate, and advocate for patients on an ongoing basis, not just when they’re in the doctor’s office. This extension enables physicians to stay connected with patients after they’ve gone home, improving adherence to their plan of care and preventing many emergency visits and re-admissions. The right model can address physicians’ fears and make it easy for them to improve care for patients between office visits. 

Drew Kearney, JD, is cofounder and CEO of 

. He has significant expertise identifying reimbursement trends, regulatory and legislative risks, federal and state-level policy developments, and shifts in industry outlook. Drew’s primary focus is population health, payment reform, and HIT. 

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Taking care of patients beyond the office setting is critical to optimizing patient’s health and satisfaction.