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Solo Docs Build Remote Teams to Tackle Chronic Care Management

A remote chronic care management team allowed a solo practitioner to implement a strong patient engagement strategy, despite lack of personnel resources.

solo practitioner chronic care management

Source: Thinkstock

By Sara Heath

- It seems as though all clinicians have adopted some form of a chronic disease management strategy that engages patients in between visits and aims to quell the negative impacts of a chronic illness. But despite the universal imperative for chronic care management, that feat remains more difficult for some providers than others.

The solo doctor, for example, might lack the personnel to deliver comprehensive chronic disease management on his own, even though he may have just as many chronically ill patients as a larger primary care practice.

But in the age of value-based care models such as accountable care organizations (ACOs), the imperative for quality chronic disease management persists nonetheless. No matter how small the practice, physicians need to keep their patients engaged between visits in order to achieve optimal outcomes – and optimal reimbursements.

 For Peter Weigel, MD, who owns the New Jersey-based Medical Associates of Westfield, the solution was simple: have someone else do the chronic care management.

“For me to have tried to doing chronic care management on my own, that just wasn't something I was going to be able to do,” he explained in an interview with

READ MORE: Why Patient Behavior Change Is Key for Chronic Disease Management

This “outsourcing” of chronic disease management doesn’t mean Weigel doesn’t interact with or engage his patients. Instead, he uses a remote chronic disease management service to supplement what he has been doing for years. This service, provided by Wellbox, helps make ends meet as Weigel documents chronic disease management for his eligible Medicare population.

The program works like this: Weigel meets with his chronic illness patients at the typical three- or four-month intervals and documents their progress into the EHR. In between visits, remote nurses or nurse practitioners call the patients and provide patient education, track medication adherence, discuss the importance of and monitor adherence to preventive screenings, and other key chronic care management touchpoints.

From there, the remote provider documents patient data for Weigel to review before seeing the patient on his own. Through the power of health IT interoperability, the remote provider is able to document within Weigel’s own EHR, yielding a high level of digital care coordination between providers.

Working with a third-party and remote chronic care management team isn’t always easy, Weigel conceded. Not all providers would feel comfortable with such a new approach to chronic care management. After all, some providers struggle with their patients seeing other members of their own practice, never mind an outsourced or remote provider.

“It's important to have a level of trust with care team members,” Weigel stated. “You want them to be able to provide the same kind of care that you yourself provide. I want a service where I read the notes and the notes sound like something that are coming from my office that I would be happy to see in the chart.”

READ MORE: Primary Care Time Constraints Limit Chronic Disease Management

If Weigel had reviewed notes that didn’t say anything substantial, didn’t adhere to his own chronic care management priorities, or had careless errors related to spelling or grammar, it would have been difficult to establish trust.

As it stands, however, Weigel and the remote chronic care management providers are on the same page when it comes to patient engagement and care. After Weigel has seen consistent quality care from this “outsourced” team, he has developed a seamless level of trust.

“These notes have a lot of good information in them and include things that I would basically be telling the patient as well,” he explained. “This includes exercising, losing weight, sticking with the medicines, make sure you see your specialists when it's appropriate, make sure you're getting your preventive treatments, your colonoscopy, mammograms, PSA testing, different things like that.”

Seeing improvements in patient health has also helped Weigel develop trust with remote care team members. Anecdotally, Weigel has seen patient hospitalization rates go down since he began his program in 2015, which is the hallmark of a good chronic care management plan.

“Looking at my hospital census from pre-2015 and now, I have fewer people in the hospital and that's due in large part to the chronic care management and the follow-up care,” Weigel stated. “If there's an issue, the chronic care coordinators will actually call my office or send me an email and say, ‘Mrs. Jones is having this problem. I think you need to reach out to her.’”

READ MORE: Overcoming Patient Barriers to Chronic Disease Management

“Again, that's just another level of care. It's another touch point where the patients are being contacted, so there's less time between office visits or between contact for things to go south,” he said.

To be clear, Weigel is still the care team leader and still plays an instrumental role in chronic care management, he reiterated.

“I'm still seeing the patients on a regular basis, every three months or four months,” he noted. “This is just additional touch points. The more patients with chronic illnesses, or any patient really, are involved with the healthcare system and with their provider, the more likely it is that they're going to be compliant with the treatment plan.”

Weigel predicts chronic care management will remain a prominent healthcare imperative going forward. Healthcare professionals may call it by a different name or tuck it into another payment model, but as long as the industry pushes toward value-based care, chronic disease management will be essential.

For providers going it alone, developing a network of care team members will be essential. For Weigel, outsourcing these services has been key to his success.

As a solo practitioner, chronic care management adds a workload that would otherwise be impossible. As the call for better patient engagement in chronic care management grows louder, smaller providers may consider alternative strategies to delivering this service to their patients.


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