Chronic Care Management

Chronic Care Management



Effectively providing superior care and providing continuous, long-term patient engagement among individuals with chronic conditions is a challenge world-wide. Patients with chronic conditions must typically manage from their home setting. As a result, the key to driving adherence is providing a care plan beyond the clinical setting. This becomes especially important for organizations adapting to value-based payment models as they attempt to keep pace with chronic care growth. Organizations must carefully consider scale, capacity and ways to continuously activate and engage chronic care patients toward measurable outcomes within specific resource constraints.

Through West’s Engagement Center and healthcare notifications, we deliver comprehensive solutions that combine technology-enabled communication with clinical managed services. The goal is to optimize chronic care and transition care management, drive scale and capacity in care coordination programs and deliver greater levels of patient engagement and activation.

Technology-enabled communications include:

  • Program enrollment and preferences
  • Biometric telemonitoring
  • Medication adherence
  • Lifestyle and education interventions
  • Appointment and lab reminders
  • Lab prep instructions

Clinically Managed Services

West’s clinical staff includes certified clinicians and registered nurses who are trained to handle and resolve issues ranging from simple call triage and exception-based interventions to more complex care coordination interactions related to medications or adverse events. We also leverage our clinical expertise to establish new chronic and transitional care programs in places where they are none existent today. The end result allows you to scale up with confidence quickly while driving additional revenue into your business.

  • Call triage
  • Care coordination
  • Exception-based interventions
  • Summary reporting for Medicare reimbursement

Additional information and resources:

West Engagement Center

Biometric Telemonitoring

Journaling keeps patients on track by automating the capture of self-monitored readings at specific intervals defined within the care plan. Our journaling applications allow you to capture readings in the patient’s preferred communication channel, including voice, SMS, email or remote monitoring integration. Smart decision-making detects when a reading is out of range and connects the patient to a care coordinator or clinical resource. When a patient misses a reporting window, a proactive text or automated voice outreach is made to collect the reading.

Journaling applications include:

  • Blood glucose
  • Blood pressure
  • Pulse
  • Weight

Additional information and resources:

Reporting Blood Pressure Readings Video
Simple Ways to Incorporate Remote Monitoring Video
Exception-based Interventions Increase Efficiency Video

Medication Management

Reduce medication errors and improve medication reconciliation to avoid adverse events and readmissions. West’s automated outbound applications provide comprehensive medication management that help you reduce gaps in care, meet regulatory requirements and ensure patients are successfully following their care plans. If non-adherence or other medication-related concerns are detected during an automated interaction, West’s intelligent call routing uses smart decision-making to immediately route the patient to an available clinician.

West’s automated inbound and outbound medication management applications include:

  • Medication reconciliation
  • Medication adherence
  • Medication change survey

Follow-up & Appointment Reminders

Engage and motivate patients with chronic conditions to get the right follow-up care. West’s automated reminders reduce the administrative workload for manual appointment management while helping to ensure patients get the care they need.

Applications include:

  • Make-Appointment Notification
    Notifies patients when it’s time to schedule an appointment.
  • Upcoming Appointment Reminder Notification
    Reminds patients of scheduled appointments and provides directions and other information if needed.
  • Appointment No-Show Notification
    Notifies patients of missed appointments and prompts them to reschedule.

Additional information and resources:

Automating Appointment Confirmations and Delivering Provider Directions Video

Lifestyle Interventions & Education

Promote self-monitoring and increase adherence to physical activity and healthy eating goals to improve the overall success of chronic care plans. These targeted applications support home-based monitoring and Internet-based interventions, as well as augment live staff calls by automating patient communications for:

  • Performing initial program enrollment
  • Providing ongoing assessment and adherence
  • Delivering positive encouragement

Tobacco Cessation

Meet regulatory requirements, flag patients for tobacco counseling conversations and provide cost-effective and sustained cessation support and monitoring. West’s automated tobacco use and cessation applications can be used in a standalone manner to augment staff call back efforts and even to connect clients to an available counselor.

Applications include:

  • Record smoking status
  • Smoking cessation support