Is Your Care Management Program Just Reporting the Weather – Or Actually Changing It?

We talk a lot about care management in value-based care. We track the metrics, pull the reports, monitor utilization trends… and we should.

But here’s a question we need to be asking ourselves—especially as we head into NAACOS next week:

Are we just reporting the weather? Or are we actually changing it?

Because at the end of the day, if your care management program is just tracking data without triggering action, you’re not managing care.  You’re narrating it.

 

What Does “Reporting the Weather” Look Like?

It looks like this:

• A monthly report showing that 13 patients were admitted to the ED—again.
• A dashboard flagging open gaps in care, with no record of outreach.
• A beautiful chart showing which patients are high risk, without any tools in place to actually manage that risk.

Sound familiar?

We’ve worked with ACOs across the country who were drowning in reports but starving for action. The care team was doing everything they could—making calls, leaving voicemails, logging notes—but they didn’t have the data in real time, and they didn’t have a workflow that told them what to do next.

So patients slipped through the cracks. Costs climbed. And the only thing the reports showed was what already happened.

 

Changing the Forecast Starts with Changing the System

Let’s talk about what an actionable care management program actually looks like—and where you can start.

1.  Real-Time Alerts That Drive Real-Time Action:  If your data is a week old, your opportunity to intervene has already passed.

💡AaNeel Insight:  Your care team needs ADT alerts that notify them the moment a patient hits the ED or gets discharged—so they can act before that patient rebounds. 

 

Example:  One AaNeel-supported ACO used real-time ADT alerts to identify when their rising-risk patients were discharged from the hospital. Instead of waiting for the claims file to tell them three weeks later, their care team called within 24 hours, scheduled a PCP follow-up, and performed a med rec.  Result: Their readmission rate dropped by nearly 18% in one performance year.

 

2. Embedded Workflows That Prompt Action, Not Just Observation:When a care manager logs into the system, they shouldn’t have to guess what to do. The next step should be prompted automatically—based on data and priority.

💡AaNeel Insight:  Workflows should guide the team from identification to intervention to resolution, with every step documented and visible.

 

Example:  A team in South Texas used to rely on Excel spreadsheets and email chains. After implementing AaNeel’s care coordination module, they could see in real time which patients needed outreach, what action was taken, and whether the care gap had been closed. Productivity jumped. So did performance.

 

3. Risk Stratification That Goes Beyond Diagnosis Codes: It’s not enough to know who’s diabetic. You need to know who’s disengaged, who’s isolated, and who’s spiraling—even if they don’t show up on traditional risk reports.

💡AaNeel Insight:  Look at behavioral flags, social determinants, appointment patterns, and missed refill data. That’s where the next ED visit is hiding.

 

Example:  One ACO flagged a patient as “low-risk” based on claims. But when AaNeel pulled in behavioral health and medication adherence data, the story changed. This patient hadn’t filled a prescription in 90 days and hadn’t answered a call from their care team in three weeks. They were proactively enrolled in the CCM program—and avoided what would’ve been a costly hospitalization.

 

4. Outcome-Driven Dashboards That Show What Changed:  Care management isn’t just about activity—it’s about impact. A good program should tell you what worked, where, and for whom.

💡AaNeel Insight:  You need more than “calls made” or “letters sent.” You need to know how those touches moved the needle.

 

Example:  After six months of using AaNeel’s built-in analytics, one IPA was able to tie every point of outreach to a clinical or financial outcome. One campaign reduced ED visits by 12%. Another improved preventive screening rates. When they showed that to leadership? The care management budget doubled.

Let’s Talk About It at NAACOS – Booth #39

If this sounds like your care management program, you’re not alone. But the good news is—you don’t have to keep doing more with less. We’ll be at NAACOS next week (Booth #39) and would love to show you how we’re helping ACOs:

• Act on real-time insights (not week-old reports)
• Streamline care coordination and reduce team burnout
• Track and improve measurable outcomes (not just activity logs)
• Turn data into action—and action into success

If you’re headed to the conference, come find us. We’ll be the ones not just forecasting care—but changing it.

 

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Ready to Move From Reactive to Proactive? Let’s make your care management program work smarter, not just harder. 📅Request a Demo Today

 

 

 

#ValueBasedCare #ACOSuccess #CareCoordination #EDUtilization #TXAACOs #HealthcareInnovation #TransitionsOfCare

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