Care Management That Works
In value-based care, identifying high-risk patients is only the beginning. The real challenge—and opportunity—lies in managing those patients effectively. For Accountable Care Organizations (ACOs), care management is the engine that drives better outcomes, lower costs, and stronger patient engagement. But not all care management programs deliver on that promise.
To work, care management must be proactive, personalized, and powered by data. It must support care teams, not burden them. And most importantly, it must be measurable.
The Care Management Gap
Despite widespread adoption, many care management programs fall short. Why?
– Reactive enrollment based on past utilization
– Fragmented workflows across teams and systems
– Manual documentation and outreach that drain staff time
– Lack of visibility into program performance and patient progress
These gaps lead to missed opportunities. According to the Agency for Healthcare Research and Quality (AHRQ), effective care management can reduce emergency department visits by 10–15% and lower hospital admissions for chronic conditions.1
What Makes Care Management Work
Successful care management programs share key traits:
– Early identification of rising-risk patients
– Tailored interventions based on clinical and social needs
– Multidisciplinary coordination across providers, payers, and community resources
– Continuous engagement through digital tools and virtual support
A study published in Health Affairs found that ACOs using predictive analytics and virtual care tools saw a 20% reduction in preventable hospitalizations and higher patient satisfaction scores.4
Improved care management requires engaging patients. 61% of patients reported that AI-powered chatbots, like Sophie, helped with symptom self-management, reducing calls to their care team to allow them to focus on direct patient care.2
The BettrAi Approach
BettrAi transforms care management from a manual process into a strategic advantage. Our platform supports:
– Risk stratification using AI-powered models to flag patients before complications arise
– Automation of enrollment, tasks and patient engagement
– Virtual support through Sophie, our AI assistant, who engages patients between visits
– Real-time dashboards to track program performance, patient progress, and ROI
– Integrated workflows across EHRs, payers, and care teams
With BettrAi, care managers spend less time chasing data and more time delivering care. Sophie handles routine outreach, symptom check-ins, and education—freeing up clinical staff to focus on complex cases.
Structured follow-up calls led by nonphysician providers—similar to Sophie’s capabilities—increased 7-day post-discharge follow-up rates from 79% to 92%, while reducing in-person visits and maintaining comparable 30-day outcomes.4 This kind of efficiency is critical for ACOs managing large populations with limited staff.5
Hypertension Management: A Case for Proactive Care
Hypertension is one of the most common chronic conditions managed by ACOs. One of the most compelling examples of care management success comes from BettrAi’s recent hypertension initiative. In a cohort of patients with uncontrolled blood pressure, BettrAi’s platform was used to deliver personalized care plans, virtual follow-up, and remote patient monitoring (RPM).
Within six months, 52% of patients moved from uncontrolled to controlled blood pressure and 23% of patients demonstrated a 10 mmHg decrease in systolic measurements demonstrating that self-measured blood pressure monitoring and RPM are interventions to implement to improve hypertension and associated clinical outcomes.3
These results demonstrate how targeted care management virtual engagement—can drive measurable improvements in both clinical outcomes and cost savings. For ACOs, this kind of impact is not just desirable—it’s essential.
These results aren’t just numbers—they’re lives improved, teams empowered, and systems made sustainable.
Why It Matters Now
As ACOs face rising benchmarks, tighter margins, and growing equity requirements, care management is no longer optional—it’s essential. CMS continues to emphasize care coordination, remote patient management and chronic care management in its quality frameworks. Practices that invest in scalable, data-driven care management are better positioned to meet these goals and earn shared savings.
And with staffing shortages still affecting many organizations, automation and virtual support are no longer luxuries—they’re lifelines.
Call to Action
Ready to make care management work for your ACO?
Let’s talk about how BettrAi can help you deliver proactive, personalized care that drives outcomes and savings.
References
- Agency for Healthcare Research and Quality. Care Management: Impacts on Utilization and Outcomes. Published 2023. https://www.ahrq.gov
- Al-Siddiq W. Accelerating healthcare with AI: Reducing administrative burdens. Forbes. Published January 7, 2025. https://www.forbes.com/councils/forbesbusinesscouncil/2025/01/07/accelerating-healthcare-with-ai-reducing-administrative-burdens/
- BettrAi. Decreasing Blood Pressure Through Self-Measurement and Remote Patient Monitoring. Published 2025. https://bettrai.com/
- Health Affairs. Improving Outcomes Through Predictive Analytics and Virtual Care. Published 2024. https://www.healthaffairs.org
- Klein HE. Remote Monitoring Program Cuts Heart Failure Readmissions in Half. AJMC. Published October 11, 2024. Accessed October 28, 2024. https://www.ajmc.com/view/remote-monitoring-program-cuts-heart-failure-readmissions-in-half