top of page

Complex Care Patient Management - See Aida's Journey!

We believe that our most complex patient populations need to be managed in a better health care ecosystem than our traditional clinic system which has historically been effective for acute episodic and single disease management.

The average Medicare patient sees a provider 3 times a year. With traditional Chronic Care Management programs, the patient is touched about 12 times a year with a combination of 3-4 visits and an average of 8 15-minute phone calls. (Parenthetically, these phone call programs have an almost universal poor patient rating. I have spoken to 3 CEOs in the last month who are cancelling the programs after 1-2 years because the patients dislike them so much. Who knew you could upset Medicare patients?).

RHS’ model for managing these complex medical and behavioral patients uses a twice a week patient monitoring systems using text and remote patient data to risk stratify the patients and act quickly anytime a patient demonstrates mild to moderate variation to their baseline. With 24/7 access to medical information and 12/7 hotline for Acute Mental Distress, we can act quickly. And we are monitoring the patient 100 times a year – literally.

We refer to our approach as an “Early Detection Warning System” for these high-risk patients. Besides improving the quality of care for our community, the overall hospital financial impact of this program is significant with consequential increases in medical and behavioral clinic volume, ancillary services and revenue for the Medicare population. The significant increase in Medicare patients (often doubling clinic volume) has a significant impact on the Medicare Cost Report reimbursement as well by increasing the total percent of Medicare patient visits.

Sound complex? Maybe. We would like to think of the program as elegant... and effective. Meeting the needs of our complex patients is arguably the most significant gap we have in our rural primary care. So, meet Aida, a patient who participates in the program and watch her journey with the help of RHS’ Early Detection Warning System. A program designed to improve the care of our highest risk patients which also reduces patient losses from our rural communities.

So, please allow us to introduce you to Aida and her path to wellness!

About Rural Health Solutions (RHS)

RHS provides solutions to our client unaffiliated rural hospitals. We have over 30 years of experience working with more than 200 hospitals and ambulatory care organizations across North America to improve financial viability, staffing, patient access, quality of care and patient experience. Learn how RHS has helped other rural hospitals increase their long-term financial viability at or contact us at

12 views0 comments
bottom of page