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.
“The Operation Matters More Than Any Single Program” puts these numbers into the weekly and monthly rhythm, and “Bill Only for Care That Helps the Patient” shows how to choose the measures that show whether patients were helped. A short version is printed in the book’s appendix “Between-Visit Tools and Fact Cards Are in the Online Companion.” The print version lists each measure and its definition without the “What it tells you” column.