Produce Every Between-Visit Care Number by Program, Every Month
The Core Between-Visit Care Scorecard
Companion to Getting Paid to Do the Right Thing · Updated 2026-09-29
A practice running between-visit care should be able to produce every number on this page, by program, every month, without a week of spreadsheet work. If it can’t, the gap is the first finding. The metrics fall into five groups, and each group answers a different question the partners should be asking.
The core scorecard. Each group answers a different question: are we finding patients, are we doing the work, is it paying, is it helping, and will it last?
| Metric | Definition | What it tells you |
|---|---|---|
| Capture | ||
| Offer rate | Patients offered ÷ patients eligible | Whether anyone is working the eligibility list |
| Enrollment rate | Patients enrolled ÷ patients offered | Whether the enrollment conversation works |
| Engagement rate | Enrolled patients with any contact this month ÷ enrolled patients | Whether the program still fits the patients in it |
| Service completion rate | Patients who met the program’s requirement this month ÷ enrolled patients | Whether the team has the capacity and the queue to do the work |
| Operations | ||
| Admin minutes per patient-month | Human minutes spent finding, chasing, counting, reconciling, and re-keying, ÷ enrolled patient-months | The Administrative Denominator; the number the practice controls |
| Care minutes per patient-month | Human minutes of work a patient would recognize as care, ÷ enrolled patient-months | Whether the program is delivering attention |
| Escalations past deadline | Open escalations older than the practice’s own response standard | Whether the humans are the bottleneck |
| Alerts acted on | Alerts that led to a clinical action ÷ alerts that reached a clinician | Whether the data streams are feeding care or feeding an inbox |
| Economics | ||
| Collection rate | Claims paid ÷ claims billed | Whether the record proves the work |
| Contribution margin per enrolled patient-month | Collected revenue minus labor, technology, and device cost, ÷ enrolled patient-months | Whether the program pays for itself |
| Days to bill | Median days from the end of the service month to claim submission | Whether Collect is part of the loop or an afterthought |
| Quality | ||
| Program-specific clinical measure | One measure chosen before launch (blood pressure control, readmissions within 30 days, A1c, ED visits) | Whether the program helps |
| Patient-reported value | Share of enrolled patients who would tell a friend the program helped them | Whether patients see it as care or as a bill |
| Honest Standard exceptions | Notes, consents, or services that failed one of the seven tests on monthly review | Whether the program is drifting toward billing for its own sake |
| Durability | ||
| Attrition rate | Patients who left the program this month ÷ enrolled at the start of the month | Whether the program keeps its patients |
| Single points of failure | Program steps only one person knows how to do | Whether the program survives a resignation |
| Staff turnover in care roles | Care coordinators, nurses, and navigators who left in the trailing twelve months | Whether the job is designed to be done |
A program that looks good in one group and bad in another is telling you where to look. A high collection rate with a low engagement rate means the practice bills well for a program patients have stopped using. A strong clinical measure with a negative margin means the program helps and the operation is too expensive, which is the problem technology is for.