Partner Care Optimization Initiative

A Success Story in Proactive Patient Care

Executive Summary

The TimeDoc Partner Care Optimization Initiative was launched to identify and serve Chronic Care Management (CCM) patients with outstanding preventive health needs that had not yet been addressed within their care plans. The initiative focused on two clinically significant gaps: unscheduled Annual Wellness Visits (AWVs) and open preventive screenings, including colonoscopies, mammograms, and HbA1c lab tests. Over seven days, a dedicated team of Care Coordinators conducted structured outreach to patients identified as having unmet care needs, guiding them toward the appropriate clinical resources and scheduling support – while ensuring that all care coordination activity was thoroughly and accurately documented.

The Strategy

The initiative ran for seven days beginning April 22, 2026. A core team of 10 Care Coordinators (CCs) led structured, manual outbound outreach to Chronic Care Management (CCM) enrolled patients who had been identified as having specific unmet preventive health needs in their care plans.

To ensure the outreach delivered maximum clinical value, conversations were laser-focused on specific, high-priority health topics:

• Annual Wellness Visits (AWV): Verifying if the patient had completed their AWV and assisting with scheduling to maintain continuity of care.
• Gaps in Care (GIC): Addressing outstanding preventive health screenings, specifically focusing on colonoscopies, mammograms, or HbA1c tests.

Care coordinators utilized their clinical expertise to guide these conversations, ensuring patients received necessary care pathways efficiently and within compliant, standard timeframes.

Challenges

Complex Care Needs Often Require More Than One Touchpoint

CCM patients often manage multiple chronic conditions with complex, overlapping care needs. Even when patients are engaged and willing, a single interaction frequently isn’t sufficient to address every outstanding health need – whether due to time constraints, the need to consult a family member, or simply the cognitive load of managing multiple health topics at once. Proactive, structured follow-up is essential to ensure every patient has the opportunity to fully address their care needs at a pace that works for them.

No Systematic Mechanism to Identify High-Need Patients

Partner practices lacked a scalable process for identifying and proactively contacting CCM patients with specific, unresolved care gaps before those gaps became clinical concerns.

Unresolved Patient Health Gaps

Patients enrolled in CCM still had outstanding preventive care needs, such as unscheduled AWVs and open health screenings, requiring proactive intervention to prevent adverse health events.

The Solution

Targeted Clinical Outreach

A core team of 10 Care Coordinators conducted manual outreach to CCM patients with outstanding clinical needs near the end of the monthly cycle. CCs efficiently addressed high-value health topics, specifically scheduling AWVs and closing clinical gaps, ensuring complete care delivery.

Meticulous Documentation & Cross-Team Collaboration

To ensure continuity across the outreach effort, CCs documented each outreach encounter with specific clinical context, logging interactions as either “AWV Outreach” or “GIC Outreach” to reflect the clinical purpose of each contact. This enabled the Inbound Call Team (ICT) and broader CC staff to seamlessly continue any conversation upon patient callback, creating a unified workflow where no patient need was overlooked.

Key Results

The initiative demonstrated meaningful clinical outcomes achievable when care coordination is driven by patient need and supported by thorough documentation. In seven days, the team achieved: