Engaging Patients Throughout Enrollment

Here are a few helpful questions and tips to ask or follow for continuous engagement:

(1) Take a look at your feedback reports

• What is new with your patient? What are the measurements telling you? Are there risk concerns? Are there any unexpected changes that need to be addressed?  

• The important thing here is to ensure that you are following up on the information you learned by viewing the feedback reports. 

(2) Check in

• Call your patient, check in with them. Have they followed through on their care plan? Have they tried new skills you went over in your last time you met? Did he use any of the resources you provided? Do they have questions for you?

• Check in with the PCP. Do they have any updates? This may be especially helpful if your patient is not responsive to your calls.

• Be sure to focus and listen to what your patient is reporting to you. What are their concerns?

• Set a concrete date/time to check back in with patients to improve the likelihood that they will be available at the time you reach out. 

• Note: There may be a time that your patient may seem disengaged; when this happens, it is best to ask them directly and be open to their feedback about the care plan. We are all human, and sometimes ruptures in the relationship can happen. The key here is to facilitate direct, open communication in a non-defensive and collaborative way.  When ruptures happen, part of your job as a care manager is to try to repair and re-engage whenever possible.

(3) Review

• Review the Care Plan. How are things progressing?

• If progress is not moving in the direction anticipated, it's okay to switch things up and try something new. This may also be a time to pull in other care team members (PCP, Psychiatric Consultant, and/or Behavioral Health Clinician) for their feedback.

• If progress is moving in the direction anticipated, then great! You can always add a new goal to the plan and/or think about discharge planning. 

• This may be a time where you need to review and/or provide interventions, skill building, and/or psychoeducation. 

• The most important thing to note here is that nothing is set in stone, and anything can be changed. Remember the patient is at the center and their feedback is crucial. 

(4) Follow-Up

• What are the next steps needed so that the care plan does not fall through the cracks? Do you have phone calls to make? Referrals to go out? Collaterals to connect with? Is your documentation clear and in the correct place? Is everyone aware of the plan? 

• Be sure to clearly communicate with your patient and the care team the next steps related to your patient’s plan, this ensures that everyone is on the same page.