Doctor's Corner: Practice Care Management and Its Role in Direct Care
- Dr. Mike
- Dec 18, 2025
- 3 min read
Updated: Dec 22, 2025
When I recently saw "Practice Care Management", my gut reaction was to think I wasn't interested and then I moved on. However, my ignorance of what Practice Care Management (PCM) bothered me, so I returned to it to learn more about what it was and how it applied to our current practice.
Briefly, PCM refers to the administrative and operational oversight of a medical practice, including tasks like scheduling, billing, patient records, staffing, and compliance. In the traditional, insurance-based practice of medicine, participating in PCM, chronic care management (CCM), and transitional care management (TCM) can be seen as a way to improve patient care, for physicians to get compensated for their time spent on tasks that did not involve patient-facing activities yet remained important in patient care, and for facilities to get compensated for patient care when employees were engaged in important tasks that had previously not been revenue-generating.
Direct care clinics may want to consider implementing some form of practice care management (PCM) to deliver proactive "whole-episode" care that boosts patient loyalty, differentiates services, and stabilizes membership revenue—without relying on chronic care management (CCM) billing. Proactive elements like risk stratification, medication reconciliation, team-based protocols, remote monitoring, and post-acute follow-up reduce high-risk hospitalizations by at least 5%, emergency visits by 25–60%, and readmissions by 20–40% via telemonitoring, improving chronic control. For membership models dependent on retention and referrals, embedding PCM enhances outcomes, justifies premium tiers, and proves value to employers by lowering total care costs.
Importantly, implementing a formal PCM/CCM program in a direct care clinic is likely impractical, especially with the requisite software having substantial cost and time commitment. Given implementing PCM can affect patient outcomes, I looked into what components were found in PCM programs and built a framework around what may be considered in a direct care clinic. Again, the intention isn't to expect you build an elaborate spreadsheet for each patient tracking a plethora of variables, but more to be aware of items you may want to incorporate in your practice when practical.
Patient Care Management Categories
1. Patient Identification, Risk Stratification, and Baseline Assessment
2. Patient-Centered Goal Setting and Care Planning
3. Medication Reconciliation and Adherence
4. Protocol-Driven Clinical Management
5. Team-Based Care Coordination and Communication
6. Remote Monitoring and Technology Integration
7. Patient-Reported Outcomes and Functional Status
8. Patient Education and Self-Management Support
9. Care Transitions and Post-Acute Follow-Up
10. Quality Measurement and Continuous Improvement
11. Billing, Compliance, and Revenue Capture
One of my next questions was to ask if some of the common medical records systems used in direct care were already capable of the tasks involved in PCM. I looked to our friends Perplexity.ai and ChatGPT.com to build a table comparing the medical records systems against the above categories, show below. In the image below, I also show the AI's opinions on which software might be suitable to combine with the selected medical records, though know I did not exhaustively evaluate the compatibility. I did look at our clinic's medical records system and the paired PCM software and saw that it would be multiple thousands of dollars annually to use the software.
In the end, I see value in direct care clinics incorporating some degree of PCM with the intent of improving patient care and patient satisfaction. While most of us have lived through a world where "metrics" was a dirty word that caused physicians emotional pain and cost physicians thousands of dollars of lost revenue in what seemed to be capricious policies, implementing some form of PCM will allow us to self-regulate and potentially identify our own metrics of interest to help our patients.
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