The IT Director’s Guide to Implementing Patient-Centered Care Management Software

Patient-centered Care Management software is an invaluable tool — not only for patients, but for clinicians, care managers, and administrators. It addresses the needs of healthcare professionals on interdisciplinary care teams who prioritize the integration of patient values, preferences, and goals into clinical decision-making to improve health outcomes and quality of care.

The New England Journal of Medicine reports that patient-centered workflows are powered by shared decision-making — giving patients, patients’ families, and caretakers a say in care plan decisions along with the time to research before making those decisions. Customizing care requires treating each patient as a unique individual who deserves to choose from multiple diagnostic and treatment options and to know the success rate data for each. Effective Care Management software solutions can help you accomplish this focus shift to streamline patient care and build trust.

How Care Management software enables patient-centered care

Efficient and effective communication is vital to gain patient trust, gather real-time data, and promote patient engagement. Implementing premium Care Management software can help you achieve the following:

Closed-loop communication with patients

As it does for the U.S. military, closed-loop communication confirms that senders and recipients receive and understand messages to avoid errors, misunderstandings, and false assumptions. Achieving successful closed-loop communication in healthcare settings requires next-generation Care Management software solutions.

Electronic health records and patient-centered Care Management software programs help streamline patient-provider communication by providing each clinician with all relevant HIPAA-compliant patient data — from the first real-time care plan touchpoint to the last follow-up.

Sharing care plan observations and real-time data and research the care team has gathered goes a long way toward a patient’s care plan compliance and lifelong trust. Implementing patient-centered Care Management software solutions can bolster patient engagement and, eventually, patient outcomes.

Higher patient satisfaction

Patient satisfaction reflects how well a healthcare system aligns with a patient’s expectation of care, as described by the JAMA network. Patient-centered care helps increase patient satisfaction rates via shared decision-making. When a patient’s participation drives the care plan and gives clinicians a clear idea of how to exceed expectations, patient satisfaction rates go up significantly. And satisfaction is often followed by patient engagement, which helps improve patient outcomes.

More highly informed and educated patients

You can’t benefit from a patient-centered Care Management platform if the people who need your expertise can’t locate or travel to your offices, clinics, or health systems. To receive ambulatory care, your future patients must be aware of your facility and the transportation options available to reach it. When you automate closed-loop communication with interdisciplinary care teams using Care Management software solutions, you expose your clinicians to a wider range of prospective patients.

Once they’ve learned about you and booked an appointment, curious, intelligent patients will be watching to ensure clinicians don’t patronize and condescend when informing them about their chronic conditions and treatments. Nurses often provide the first touchpoint with patients to set the stage for patient engagement and patient portal functionality. According to the Journal of the American Academy of Nurse Practitioners, effective patient-centered care practices require consistent communication, shared decision-making, and user-friendly patient education — which is often introduced to patients by nurses.

When care managers share care plan and pricing details honestly (even when they’re not sure about a particular treatment’s efficacy in their case) they garner trust and respect — promoting patient engagement and care plan compliance for years to come.

How patient-centered Care Management software benefits your care team

Your care team and administrators are probably using electronic health records (or EMRs) that simply digitize paper processes — like digital filing cabinets with problem lists in one file and communications in another. Although EMRs can automate clinical processes to a certain extent, they’re not able to suggest new workflows or stratify and identify high-risk patients to enable optimal, analytics-based decision-making for clinicians.

Properly implemented and consistently utilized patient-centered Care Management software allows clinicians, care managers, and patients to meet their goals. That’s because streamlined care plans foster consistency to help you achieve the following:

Decrease clinician burnout

Stressed-out clinicians find it difficult to prioritize more robust, real-time communication when juggling administrative tasks with tightly scheduled patient appointments and touchpoints between appointments. Most EMRs were built with so much functionality that it made following patient information throughout each health journey difficult for clinicians and care managers.

When lab results and patient information are buried in multiple menus and sub-menus, it’s extremely time-consuming to access. The focus of the EMR system is on ensuring that specific codes and data are accessible to satisfy billing — not on streamlining and nurturing patient care plan journeys in real-time.

When interdisciplinary clinicians interact and collaborate using Care Management software solutions, however, streamlined workflows and centralized automated communication hubs can help alleviate burnout, enabling care teams to implement their ideal vision of patient-centered care.

Ensure continuity of care

Patient-centered Care Management does not end when the patient leaves your health system or hospital room. In order to keep a patient’s family fully vested in care plans, your care team should have immediate access to patient information on physical limitations, behavioral health, dietary requirements, medication schedules, and treatment preferences. Sharing this patient information in real-time helps clinicians coordinate ongoing care plans and provides physical, clinical, social, and even financial support.

Clinicians can empower patients by explaining care plans in detail so they never feel helpless. Flexible, user-friendly care coordination of front-line patient care, clinical care, ancillary care, and support services promote patient engagement and loyalty. Care Management software solutions automate follow-up, ensuring each clinician is informed about each step in each patient’s care plan.

Improve clinician job satisfaction

Despite its name, patient-centered care offers just as many benefits for providers. This holistic healthcare approach will help improve morale and job satisfaction for care providers and administrators alike. When clinicians feel like they work at a healthcare organization that focuses on patient-specific needs — more specifically, one that implements quality improvement measures — they are more likely to feel satisfied with their job and less likely to experience burnout.

Many clinicians consider it a moral obligation to honor the wishes of their patients and their patients’ families before sharing a diagnosis or recommending treatment. The Annals of Family Medicine describes clinicians’ initial concerns about patient-centered care, because: “its focus on individual needs might be at odds with an evidence-based approach, which tends to focus on populations.” After observing positive patient outcomes for decades, however, they’ve understood that their approach to a patient’s values and needs can either enhance or delay healing.

Recently, the National Institutes of Health found that clinicians who reported successful patient-centered care in their facilities were more likely to have higher morale, less burnout, and greater job satisfaction. Both providers and support staff thrive in a more efficient, satisfying work environment.

Streamline resource allocation

Transforming a healthcare system into a patient-centered healthcare hub is not easy, but once accomplished, the transition enables your care team to more efficiently allocate resources. Rather than spending time and energy proposing and implementing diagnoses and treatments that patients will reject or ignore, you can work with them to find an option that makes sense to them.

Reprocessing visits and test results every time a patient needs to see a new specialist with a different perspective is inefficient and costly. Patient-centered Care Management software enables your team to craft holistic care plans in collaboration with all parties from the start.

You won’t have to spend a large portion of your budget on various platforms with a healthcare-specific Care Management platform that allows you to streamline your workflow in order to maximize time and energy spent on the patient — not data processing. By reducing “click fatigue” for your clinicians, you conserve their most precious resource: energy and focus.

Improve outcomes

The AMA Journal of Ethics® has reviewed decades’ worth of research that demonstrates how prioritizing patient values and preferences inspires patients to engage more in treatments, leading to better health outcomes. Hospitals and practices that implement patient-centered Care Management software report:

  • Lower ER visit rates
  • Faster recovery
  • Decreased utilization of healthcare resources
  • Increased patient, family, and care team satisfaction
  • Improved health outcomes

Relias Media found that care teams that leverage effective Care Management software dashboards see their patients’ outcomes improve.

Reduce care costs

Holistic, preventive, patient-focused care models aim to prevent disease rather than treat it once it’s reached more dangerous and expensive stages. A study conducted by the Primary Care Collaborative compared patient-centered practices with traditional practices. Patient-centered providers achieved higher improvement in diabetes control and screenings of colorectal and breast cancer, as well as lower hospital admissions costs, emergency room visits, and total cost of care.

A Horizon Blue Cross Blue Shield study found that patients who participated in patient-centered programs had a 9% lower total cost than those who participated in traditional fee-for-service care models. Patients who received patient-centered care were also 8% less likely to be admitted to a hospital and 5% less likely to end up in the ER. Patient-centered Care Management software can assist in achieving these results more effectively and efficiently.

Identifying what an individual patient does and does not need can eliminate unnecessary expensive tests, reduce hospital admission rates, and reduce ER visits — all of which lower the total cost of patient care. When health insurance companies reward clinicians for meeting clinical, efficiency, and patient satisfaction benchmarks, everybody cuts costs.

Enhance your reputation

Thanks to online reviews and social media, it’s easier than ever for your patients to discover and influence your reputation. Healthcare professionals cannot view patients merely as individuals seeking treatment for one condition — patients are healthcare consumers expecting the exceptional benefits of genuinely patient-centered care.

A Medical Principles and Practice study conducted in Spain revealed that a healthcare organization’s social reputation and how patients — and relatives of patients — perceived patient safety at its facilities were directly correlated. In other words, the patient perception that the hospital was a safe clinical environment that committed very few errors was a key component of that facility’s positive reputation.

Shared decision-making between the patient and their care team ensures that the patient feels they are being taken care of and that all safety precautions have been implemented. Patient-centered Care Management software can help make healthcare safer, more accessible, more equitable, and more affordable. It can enable patients, caregivers, clinicians, employers, and insurers to make informed health decisions and achieve better outcomes … which makes them more likely to enhance your reputation in their reviews.

Choosing the optimal patient-centered Care Management software

If it’s going to enable patient-centered care, your Care Management software must feature the following attributes:

Easily integrated

Your patient-centered Care Management system should not be bound by a single EMR. You want to choose one that spans a variety of other data sources. This enables communication across the entire care team, which can comprise patients, acute care, primary care, specialty care, therapists, social workers, Care Managers, and caretakers.

When there are multiple health systems and employers collaborating in a wellness program, the variety of data sources and care team members grows even more complex. Your Care Management software should pull data from every system and manage all communications. It should allow your team to automate actions, set preferences, and create workflows for your unique environment; make sure they work with your existing and future systems.

As Health Catalyst explains, this Care Management software interoperability is especially critical in Accountable Care Organizations (ACOs) — amalgamations of healthcare systems working together to minimize population risk or a system that grew via mergers and acquisitions. When each health system has its own EMR, data systems following the patient journey can be incredibly challenging, which is why robust Care Management software is the optimal solution for promoting integration and patient-centered care.


The Care Management software you choose should feature a well-documented application programming interface (API) that was built specifically to perform the functions your care team and administrators need.

When reviewing Care Management software, look closely at the level of customizability. With leading integrated applications already built in, along with an API that allows you to build whatever else you want, you can create software that works exactly for your practice — both in its current capacity and as it grows.

APIs allow for easy program design. Don’t choose Care Management software that was designed with the assumption that you have a developer on staff. Go with a solution that allows your team to configure or modify programs without hiring engineers or developers.

APIs enable intelligent workflows. Always test-run any Care Management software you’re considering to see how easily it allows your team to practice patient-centered care. Make sure your chosen program makes communication simple and intuitive for patients while enabling clinicians to quickly and easily manage patient data across specialties and facilities.


Effective care teams and administrators track the success of each care plan or communications campaign. That means your Care Management software should enable clinical analytics; with this, you’ll have a system that tracks trends and patterns to drive better outcomes for patients and adjust day-to-day workflows for clinicians.

Any truly patient-centered Care Management software features embedded analytics, machine learning, and data-driven quality improvement capabilities. Leading AI-driven embedded analytics platforms like Sisense allow your care team to view or build your own dashboards and reports. This enables team-first care delivery, providing clinicians and administrators with the right intelligence at the right place and right time.

Automated assessments and reminders for clinicians, coaches, and patients will help your team deliver high-quality care for the patients who need you most. So make sure you understand and can easily navigate the analytics capabilities of any Care Management software you’re considering.

Risk management-friendly

Stratification — knowing which patients to drive changes for and when — is the holy grail of Care Management. It’s the most efficient way to identify and provide care for high-risk patients who typically have multiple comorbid conditions and socioeconomic considerations.

Clinicians generally fall into 2 categories: specialists focused on a single condition or human organ system and primary care physicians with broader, cross-disciplinary expertise. Effective Care Management requires the skills of both.

One clinician would find it very difficult to treat a patient with 8 comorbid conditions and 20 daily or weekly medications. When a care manager prioritizes one condition, like depression, for example, their intervention for it might disrupt another specialist’s care plan for another condition. Care Management software can automate decision-making on a day-by-day, or even hour-by-hour basis to define which risk is higher when, and which interventions should take priority.


Effective IT directors know the importance of HIPAA compliance. Make sure your patient-centered Care Management software enables you and your associates who are subject to the U.S. Health Insurance Portability and Accountability Act of 1996 (HIPPA) to use its secure environment to process, maintain, and store protected health information. You should also be familiar with the Office of the Inspector General (OIG) of the Department of Health and Human Services’ seven fundamental elements of an effective compliance program.

A HIPAA-compliant Care Management software with an accessible and well-documented API will allow you to create a compliance program that can reduce fraud, abuse liability, and waste. If the Care Management software that you’re considering isn’t HIPAA compliant it’s not a comprehensive enough solution to protect your care team from optical character recognition (OCR) audits and fines. Make sure you’re leveraging Care Management software with HIPAA-compliant Zoom for Healthcare integration that includes:

  • HIPAA self-audits
  • HIPAA remediation plans
  • HIPAA policies, procedures, and training
  • HIPAA documentation
  • Protected health information (PHI) incident management

Highly secure

Make sure your chosen Care Management software features the strictest healthcare security standards. Ideally, it should undergo an independent third-party Service Organizational Controls Type 2 examination every year. This will ensure your patient data has the highest level of security, availability, and confidentiality.

Next-generation Care Management software has a time-stamped audit trail that tracks who, when, and where user-level changes were made. A robust security log allows you to track every security action taken. You can choose to leverage either multi-factor authentication (MFA) or single sign-on authentication (SSO).

Checking permissions on any Care Management software you’re vetting is critical. Protect the integrity of your data as you share it between clinicians and teams using these flexible role-based, attribute-based, and geography/territory-based security permissions.

It’s a good idea to make a checklist of these critical features when shopping around for or trying a demo of a Care Management software tool you think may help your care team and administrative staff successfully implement patient-centered care.

Measuring results of patient-centered Care Management software implementation

The first standardized healthcare assessment survey in the U.S. was the Hospital Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS®). This data collection tool was developed by the Centers for Medicare & Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ). It measures the patient experience by asking discharged patients whether they got the care they needed quickly enough and whether they enjoyed thorough, compassionate communication with doctors, care providers, and customer service representatives.

These ratings are critical to the health of your practice. They can help your care teams hone their patient-centered care plans, as well as their electronic health records management and advanced-access scheduling processes. These improvements will require studying successful patient-focused care examples and investing in Care Management software that promotes and enables team-first care delivery which, by saving clinicians’ time and energy, enables patient-centered care.

The International Journal for Quality in Healthcare has found that successfully leveraging patient-centered Care Management requires:

  • Engaging patients and families throughout the organization
  • Consistently measuring patient feedback
  • Redesigning care delivery based on that feedback
  • Incentivizing staff accountability
  • Encouraging education and change

Clinicians reported that the amount of time it took to make the provider-focus to patient-focus shift was the biggest impediment to transforming their culture.

Level up your care team with patient-centered Care Management software

Deciding to implement patient-centered care is a big decision and generating results takes time. Improve your care team’s job satisfaction, promote ideal patient care, and attract new patients by designing a holistic, patient-centered, software-enabled care plan. Then, enjoy the benefits.

Make your checklist, gather your clinicians’ questions, then schedule a Welkin demo to see how we stack up.

Make your program more care-centric today.

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