CCM&RPM
Harbor Lane Family Medicine: Enrolling a Fifth of the Eligible List.
Eleven physicians, five thousand technically eligible patients, and a deliberate decision to enroll a fraction of them.
The situation
No hiring, no training, no administrative overhead. CareNexa provides the full staffing layer, from clinical care managers to billers.
What we did
- Prioritized rather than counted. Ranked the eligible pool on recent utilization, medication count, control markers, refill gaps and prescriber count, and recommended 480 patients.
- Let the practice cut the list. Physicians reviewed and removed 70 patients they judged well managed. We enrolled from the remaining 410.
- Layered RPM narrowly. Only the hypertensive and diabetic slice where a home reading would change a decision. Around a third of the CCM cohort.
- Connected it to wellness visits. Coordinators already calling monthly booked overdue annual wellness visits during the same contact.
What happened
Of 410 approved candidates, 226 enrolled. The practice has expanded twice since, both times by a few dozen patients rather than a batch.
What was harder than expected
The medication discrepancy rate in the first quarter was high enough to be uncomfortable. Roughly four in five newly enrolled patients had at least one difference between the chart list and what they were taking. Most were minor. Several were not. The practice found this difficult to see, and it is the finding most likely to be replicated at any practice starting a program.
Enrollment conversion also sat below our own projection for the first two months, largely because the initial calls came from several patients did not recognize. Adding the practice name to the caller ID and a short heads-up at the prior office visit resolved most of it.
They came back with a shorter list than we expected and told us why each patient was on it. Every other vendor came back with a bigger number.
Practice Manager, Harbor Lane Family Medicine
If your practice looks like this
Independent primary care groups with large adult panels and no existing care management program. The value here is selection discipline; the eligible list is never the answer.
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