Younger woman leading elderly woman with cane
CCM Physician Type/Specialty RPM

How ACOs Can Leverage Chronic Disease Management Software

Beth Osborne | 20 December 2023
4 minute read

ACOs (Accountable Care Organizations) have a mission to deliver coordinated, high-quality care. Your objective is to ensure chronically ill patients get the right care at the right time while preventing duplication of services and reducing costs. Achieving these goals requires many strategies and programs, including remote patient monitoring (RPM), which can be deployable in scaled manner with chronic disease management software.

What is chronic disease management software?

Chronic disease management software is a broad term for a technology solution supporting continuous and connected care for those with chronic conditions. It can be instrumental in broadening care outside the four walls by collecting vital data and other information from patients daily. With these insights, the physicians within your ACO can:

  • Understand the progression of chronic diseases.
  • Track and monitor patients’ vital data automatically. 
  • Engage with patients by texting or calling in-platform to encourage adherence to readings and treatment.
  • Use an escalation threshold for quick responses to critical readings.
  • Adapt treatment plans,

When determining what platform to choose for managing chronic diseases, you’ll want to compare the features and services that most align with the needs of ACOs.

What should ACOs look for in chronic disease management software?

Since the introduction of RPM and chronic care management (CCM), there have been many solutions offered in the market. Each has varying features and functionality, with some being more customizable based on your organization’s structure. For example, ACOs that deploy RPM or CCM programs manage them for hundreds of physicians, which requires scalable software that can segment by clinician.

When evaluating options, these capabilities should be on your list.

Workflow integration

The software should include vitals reports and dashboards that fit seamlessly into your current processes. This may require customization, so be sure that’s possible.

Patient views

The platform you choose should have single-view capabilities for all patients. With this feature, you can access a specific patient for engagement or intervention.

Progress tracking

Part of taking daily vitals is delivering more data to physicians to evaluate treatment plans so patients don’t end up in the hospital or seeking emergency care. Your technology should enable patient progress tracking to gauge the success of current regimens.

Two-way communication

Communication is critical in chronic disease management. Patients and those monitoring them need a way to engage that’s easy. The ability to do this should be part of the software, so it’s readily available and tracking all the communication.

Billing and revenue management

Another must-have feature is the ability to manage billing and revenue. The software should make it easy to bill the correct codes and track reimbursements. 

Along with software, you also want to partner with a company that provides services for RPM and CCM programs

Patient panel analysis

Get help identifying which patients of your physicians are a good fit for monitoring. After determining who to enroll, clinical services teams can reach out to them by phone to educate them on RPM.

Insurance verification services

Use clinical services teams to help with insurance verification to understand what Medicare will reimburse you for in terms of monitoring certain patients. 

Patient onboarding

The next part of deploying a program is onboarding patients. It’s a requirement for reimbursements, and a partner can assist with this remotely, on-site, or in a hybrid framework. This will improve patient adoption and provide them with all the information they need about their connected devices and how to take their vitals. 

Connected device shipping

You won’t have to coordinate getting connected devices to patients. Your software partner can handle this with in-home delivery.

Clinical monitoring services

Should your team not have the capacity to monitor all patients, you can opt to outsource this with licensed, U.S.-based nurses. They focus on engagement and reviewing readings, escalating those that need immediate physician attention. 

Better clinical outcomes are possible with chronic disease management solutions.

Every ACO wants to improve the quality of life of chronic condition patients and reduce the risk of emergency department visits and hospitalizations. Research shows this is possible, with RPM responsible for a 25% reduction in ER visits and a 38% decrease in hospitalizations.  

You can achieve similar results and much more by adopting software like the Optimize Health platform. ACOs trust it to streamline program management. Its robust features and additional clinical services are ideal for ACOs. See how it works today by requesting a demo