Produce Every Between-Visit Care Number by Program, Every Month

The Core Between-Visit Care Scorecard

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

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.