Why Patient Selection Matters

PCM is intended for patients whose primary clinical burden comes from one complex condition. Enrolling the right populations ensures that services are:

• Medically necessary and reimbursable

• Focused on conditions requiring frequent adjustments or oversight

• Non-duplicative of CCM or other care management programs

High-Value Populations for PCM

1. Patients With a Single High-Risk Condition

Examples include:

• Heart failure requiring frequent medication adjustments

• Chronic kidney disease stage 4–5 with ongoing monitoring needs

• Severe COPD with repeated exacerbations

These patients need regular care coordination, but may not have other conditions that qualify them for CCM.

2. Patients in Active Treatment for One Complex Condition

• Oncology patients receiving chemotherapy or immunotherapy

• Post-transplant patients under close follow-up

• Neurological conditions such as Parkinson’s disease with symptom management needs

3. Patients Transitioning From Acute Care for One Condition

• Recent hospitalization for CHF exacerbation

• Acute decompensation of liver disease

• Stroke survivors requiring focused rehabilitation planning

Populations Less Suitable for PCM

• Patients with two or more chronic conditions (better suited for CCM)

• Patients receiving hospice or palliative care, where goals differ from PCM objectives

• Low-risk chronic conditions with minimal ongoing management needs

Social Determinants and Equity Considerations

PCM success depends on engagement and follow-up. Practices should account for:

• Caregiver availability for complex medication schedules

• Access to transportation for labs and follow-ups

• Language and literacy barriers that may hinder condition-specific education

• Technology access when RPM or digital outreach is used to support PCM

Enrollment Criteria and Workflow Integration

To ensure compliance:

• Diagnosis Requirement: One serious, high-risk chronic condition expected to last ≥3 months.

• Care Plan: A focused, patient-centered plan specific to the condition.

• Monthly Engagement: At least 30 minutes of staff or provider time per month.

• Consent: Documented patient agreement, including potential cost-sharing.

Workflow Integration:

• Embed PCM eligibility checks into EHR discharge alerts or specialist referrals.

• Assign responsibility to care coordinators for monthly outreach.

• Use RPM or lab tracking where relevant to monitor disease-specific measures.

Key Takeaways

• PCM is designed for patients with one complex condition that drives their care needs.

• Populations include CHF, CKD, COPD, oncology, and neurological patients with ongoing, high-intensity management.

• Practices should ensure that PCM enrollment is distinct from CCM to avoid duplication.

• Structured workflows and equity considerations improve both compliance and patient outcomes.