Health Dialog Connections

Best Practices for Integrating Population Care Managers within ACOs

A nurse coaching a patient over the phone to improve population health outcomes

At Health Dialog, part of our vision is to help health plansproviders and employers maximize the health of their populations in the most cost-effective ways. Our Population Care Management program places registered nurses, called Population Care Managers (“PCMs”), in primary care practices or within the administrative departments of Accountable Care Organizations (“ACOs”) and Patient Centered Medical Homes. The program creates value for theseproviders by delivering structured population health services that focus on care coordination throughout the care experience. Health Dialog’s PCMs dedicate about 80% of their time to providing chronic care support and about 20% on other services needed by the provider, such as  coordinating and facilitating group education sessions (e.g. living with diabetes) or participating in interdisciplinary teams tasked with developing chronic care management or wellness initiatives. Be on the lookout for my next blog post which will delve into these supplemental services.

We found there are several best practices that enable the PCM to become an active and effective member of the care team:

Establish a patient care center as a home – base

Placing the PCM in the ACO’s largest volume primary care office can promote visibility and enable direct access for patients, physicians and office staff. Placing PCMs in an administrative office setting can also be effective, but may limit the number of opportunities for valuable, face-to-face interactions. Patients may be more ready to engage with PCMs when they see them working side-by-side with their doctor.

Cultivate the role of physican champion(s)

These individuals promote the PCM role throughout the health system and lead the population health management program effort. They articulate the program goals and help set the ground rules as to how the PCM role will fit within their health system. It is the physician champion’s job to advise their fellow clinicians when it is beneficial to consult with the PCM and direct patients to the PCM. Additionally, these leaders can help support the program by providing clinical and administrative guidance to the PCM, such as; providing instruction during urgent situations when the PCP is unavailable, or setting a standard time-frame between hospital discharges and when patients should be seen for follow-up by the PCP or specialty physician.

Assign unique goals and functions

The PCM should serve needs that are presently unmet within the health system. If the ACO already has staff making outreach calls to patients just discharged from the hospital, it’s best not to ask the PCM to do this too, or else you run the risk of duplicating services and confusing staff and patients.

Set clear expectations and limit the role to specific functions

The PCM should only be assigned tasks that directly contribute to the program goals. A PCM who is rooming patients, or working the front-desk because a staff member called out, is unable to carry out the tasks essential to the success of the program.

Spotlight the role

Keep the PCM role at the forefront by calling attention to its value in provider meetings, employee and patient portals, newsletters, or emails. Highlight success stories and show concrete ways the PCM is helping providers (e.g., saving time, improving patient satisfaction, contributing to better outcomes) and the organization (e.g., contributing to success in value-based contracts).

Provide EMR access

The PCM needs EMR access to understand a patient’s medical and social history in order to identify potential barriers to care. Access to the EMR also helps the PCM establish credibility with patients and physicians, document in real-time, communicate directly with clinical staff (e.g. assign tasks), and use scheduling tools to plan for in-person interactions with patients.


The PCM should be accessible to patients and able to consult with providers, in-person, throughout the health system. Designate a location in each care setting where the PCM can privately discuss cases with office staff and meet with patients. This will maximize in-person communication and minimize disruption to the daily practice workflow. Consider equipping the PCM with a laptop, versus a desktop, to enable better mobility and overall efficiency. Seeing patients in multiple rooms within the same office or in different office settings can be challenging. A laptop allows the PCM to focus on caring for patients and not on administrative tasks, and assures timely documentation and access to evidence-based clinical tools from any location.

We are eager to hear what successes and challenges your organization has experienced when implementing Population Care Managers into your health care system.

Learn more about how Health Dialog partners with providers.



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