ChartSpan Helps Practices Provide Preventative Care for Their Patients

ChartSpan’s goal is to improve the preventative care offered to Medicare patients across the U.S., and we’re proud to collaborate with the Texas Hospital Association on that goal.


ChartSpan’s goal is to improve the preventative care offered to Medicare patients across the U.S., and we’re proud to collaborate with the Texas Hospital Association on that goal. We offer practices, hospitals, and health systems the nation’s largest full-service Chronic Care Management program. We also provide Annual Wellness Visit software, Remote Patient Monitoring enrollment, and quality improvement solutions.

Through these services, we can help your practice reduce patients’ risk of negative health outcomes, increase revenue, and identify care gaps and Social Determinants of Health (SDOH) needs.

Improve Patient Outcomes

Preventative care programs like Chronic Care Management and Annual Wellness Visits have consistently improved outcomes for patients. Patients who enrolled in ChartSpan’s CCM program experienced 12.1% fewer Emergency Department visits than patients who were eligible but didn’t enroll, thanks to features like monthly preventative care and a 24/7 nurse line.

With CCM, patients receive preventative care remotely in their homes each month. Care coordinators use phone calls and digital engagement to help patients set care goals, pursue those goals, and receive information on managing their chronic conditions.


Patients can also call the 24/7 nurse line to speak to a licensed nurse about their health concerns. The nurse will answer their questions and, if necessary, assist them in setting an appointment with their provider, going to urgent care, or calling emergency services.

Additionally, Annual Wellness Visits can play a critical role in identifying health risks before they progress to serious illness. During AWVs, patients can complete an HRA using ChartSpan’s RapidAWV™ software. Their provider can use the HRA to address cancer screenings, vaccinations, or appointments the patient needs to schedule.

Increase Revenue

Programs like Chronic Care Management, Remote Patient Monitoring, and Annual Wellness Visits can increase recurring monthly revenue for your practice, hospital, or health system. ChartSpan helps create this revenue by offering full-service CCM, software for AWVs, and enrollment for RPM programs.

Of the preventative care programs ChartSpan offers, Chronic Care Management is one of the most effective at generating new revenue, with opportunities for both fee-for-service and value-based revenue. For organizations focused on fee-for-service, Chronic Care Management ensures patients receive meaningful, preventative care that is reimbursed by Medicare every month. A practice can earn more than $100K annually with just 300 enrolled patients.

For value-based care providers, CCM offers invaluable opportunities to enhance their performance and increase revenue. Practices enrolled in ChartSpan’s CCM receive complimentary quality improvement services to help them enhance their results for the Medicare Shared Savings Program, their ACO, or the Merit-based Incentive Payment System.

While ChartSpan doesn’t offer full-service RPM, ChartSpan’s enrollment services can help practices increase their enrollment in RPM programs and therefore the program’s revenue.

ChartSpan has also seen success helping practices generate AWV revenue. With just 1,500 eligible patients, one practice earned $200,000 in additional revenue per year. A smaller practice with 400 eligible patients earned $60,000 in revenue.

By combining multiple Medicare preventative care programs, practices can increase their revenue and continue serving the patients who rely on them.

Identify Care Gaps and SDOH Needs

As Medicare continues to emphasize preventative care, practices need to focus on identifying care gaps for patients. Care gaps like not receiving a needed vaccination or screening, missing appointments, or not refilling medication are often associated with Social Determinants of Health (SDOH) challenges.

Social Determinants of Health, from housing to transportation, food security, and financial state, have a direct impact on patients’ ability to reach appointments, refill prescriptions, and follow recommended nutrition or exercise plans.

Through Chronic Care Management and Annual Wellness Visits, ChartSpan empowers providers to identify care gaps and SDOH needs. Many of these needs are part of the Health Risk Assessment patients fill out during Annual Wellness Visits. But if patients miss their AWV, Chronic Care Management offers a monthly opportunity to address these gaps with patients.

Over the course of one year, ChartSpan’s CCM team helped 19,270 patients with SDOH needs. The care managers found transportation services, directed patients to housing resources, and helped them locate food pantries and grocery delivery options. The CCM team also performed 16,770 SDOH screenings to identify unaddressed needs and shared the results of those screenings with the patients’ providers.

By addressing care gaps and SDOH, ChartSpan’s services help providers care for their patients holistically, not just during office visits.

Reach Out to Learn More about Preventative Care

We’d love to demonstrate how ChartSpan can help your hospital or health system increase your revenue, improve your patients’ long-term health outcomes, and address Social Determinants of Health. If you’re interested in preventative care programs like Chronic Care Management or Annual Wellness Visits, you can find more information at