How do we capture care manager activity?

An important first question is – do you want to capture care manager activity and for what purpose? Some practices need to know for purposes of reporting and reimbursement, but an important factor is the amount of time it takes to document versus the need for the documentation. Documentation can be very time-consuming and therefore frustrating for care managers, just as it is for other types of providers. Of course, documentation is often necessary for billing purposes, but otherwise, it is wise to consider the time and effort involved versus if that time could be otherwise used to serve more patients or serve at higher quality those patients already served. An important consideration in the process of learning to implement a new service (such as care management) is to collect data that will help you to be reflective about what is working and producing the outcomes you are hoping to achieve.

Some considerations in documentation

Some aspects of documentation to consider (but are not always needed in all cases) are the following:
• Specific patient visits
• Type of patient visit (phone or in-person)
• Length of visit
• Type of service provided (education, self-management support, care coordination, medication reconciliation, social work, mental health, etc.)
• Patient’s chief complaint, key conditions, and/or issue being worked on
• Goal and goal accomplishment
• Other individuals consulted about the patient, the time it takes, and what is discussed
• Resources accessed
• Refusals and no shows
• Patient concerns or complaints (and compliments), Incomplete calls or visits scheduled

From these data, the following can be calculated (partial list):
• Number of visits on average per patient and per type of patients
• Average number of patients seen per care manager and types of contacts (face-to-face, phone)
• Frequency of types of visits for types of patients
• Average number of months patients receive care management services
• Number of patients with improvement based on condition(s) receiving care management services, and the number of patients reaching treat-to-target
• Value to patients
• Key resources important to the care management process

What are ways to improve efficiency for documentation?

One of the key issues with inefficiency is the need for the care manager to double document. This is when the care manager has to document care in the EMR and also a separate care manager system. Since synchronous documentation (documenting in one EMR places the data in the other) is usually missing, this requires the care manager to double enter in multiple systems. This is a key complaint of many care managers. Often the data needed for reimbursement are more detailed than what is captured in the EMR, so a separate system is needed (see below). It is also often the case that EMRs are not easily (or not possible or too expensive) to be reconfigured to capture care management data.

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