Patient Engagement 101: Involving Patients in Their Own Care

On a Tuesday afternoon, Ms. Davis, a 65-year-old with both diabetes and heart failure, sits in her kitchen scrolling through her phone. Her weight has increased by three pounds in the last week, but she wonders if that is important enough to mention. In her portal, she sees a message from her care coordinator: “We noticed your weight trend and want to check in. How are you feeling today?” Ms. Davis responds, shares her shortness of breath, and by evening she has a medication adjustment from her physician. This simple, timely engagement prevented an ER visit.

Stories like this remind us that patient engagement, when structured and intentional, is not just a concept, it is the foundation of high-quality, cost-effective care. Engagement means patients are not passive recipients of medical advice but partners who understand their conditions, participate in decision-making, and commit to following through with plans. Achieving this shift requires more than good intentions. It requires frameworks, communication strategies, and tools that support engagement in daily clinical practice.

Why patient engagement matters

The importance of patient engagement becomes clear when looking at outcomes across chronic disease management. Engaged patients are more likely to take medications as prescribed, follow through with recommended screenings, and report early symptoms before crises develop. The Agency for Healthcare Research and Quality (AHRQ) has shown that patient engagement directly improves safety and reduces avoidable adverse events. For practices, this translates into lower readmissions, improved satisfaction scores, and better alignment with value-based care metrics.

In cardiology, an engaged patient might weigh themselves daily and notice fluid retention before it escalates. In endocrinology, a patient who logs and reviews their glucose readings can spot patterns, adjust behavior, and collaborate with providers on insulin titration. In primary care, a hypertensive patient who tracks blood pressure at home may be more motivated to take medications consistently when they can see improvements over time. Engagement is not about abstract empowerment, it is a practical necessity to make treatment plans succeed outside of the clinic.

Engagement also has systemic implications. In today’s value-based environment, payers and regulators increasingly expect engagement to be measurable. Documentation of shared decision-making, adherence monitoring, and consistent follow-up are core to HEDIS measures and CMS quality reporting. Practices that systematize engagement position themselves for success in these programs, while those that treat engagement as optional risk financial penalties.

Finally, patient engagement transforms the provider-patient relationship. When patients feel heard, respected, and involved, trust deepens. They are less likely to switch providers and more likely to recommend the practice. In a competitive environment, this human dimension of engagement becomes a differentiator as much as a clinical requirement.

Communication techniques in Chronic Care Management (CCM)

Chronic Care Management (CCM) provides one of the strongest vehicles for engagement. Under CPT codes such as 99490, practices are reimbursed for at least 20 minutes per month of non-face-to-face care coordination by clinical staff directed by a physician or qualified professional. These structured monthly touchpoints create space for meaningful conversations that might otherwise be squeezed into crowded visits.

The technique of communication is critical. Instead of superficial check-ins, care teams can use motivational interviewing, which emphasizes open-ended questions and reflective listening. For instance, rather than asking, “Did you remember your insulin shots?” a CCM nurse might ask, “How are you finding your routine with insulin this month?” This phrasing encourages the patient to discuss challenges, successes, or confusion. It also signals respect for the patient’s lived experience.

Technology can scale communication. Secure portal messaging, automated reminders, and symptom surveys supplement direct phone calls. These digital touchpoints keep patients connected without overwhelming staff. When a patient logs worsening fatigue in an electronic survey, for example, Lara Health’s platform can flag the response, prompt outreach, and guide staff with prebuilt scripts to ensure the communication is empathetic and compliant.

Importantly, CCM communication is not just a one-way flow of instructions from provider to patient. It is about creating a loop where patients report, staff respond, and care plans evolve. Each cycle reinforces the patient’s sense of agency and strengthens adherence.

Shared decision-making

Shared decision-making is one of the clearest expressions of patient engagement. It goes beyond consent forms and ensures that patients’ preferences, values, and goals shape clinical decisions. This is particularly important in chronic care, where trade-offs often exist. A patient with diabetes may wish to avoid medications that cause weight gain. A patient with heart failure may prioritize comfort at home over repeated hospitalizations.

Research, including publications in the New England Journal of Medicine, has shown that shared decision-making improves adherence and trust while reducing decisional conflict. CMS recognizes this as a standard of quality care, embedding shared decision-making into requirements for services such as lung cancer screening and implantable defibrillator placement.

In practical terms, shared decision-making requires structured conversations and documentation. Providers must present options clearly, outline risks and benefits, and ask about patient values. Lara Health supports this by embedding templates that capture patient preferences into care plans and prompting providers to revisit those preferences over time. For example, a patient may initially prioritize aggressive therapy but later shift toward comfort-focused care; documenting these changes ensures alignment across the care team.

When shared decision-making is part of routine practice, patients are not just more satisfied—they are more likely to follow through. A plan that reflects what matters to them feels less imposed and more collaborative. That difference can determine whether therapies succeed or fail.

Access to health data

Transparency is another pillar of engagement. Giving patients access to their health data, whether through after-visit summaries, lab results, or Remote Patient Monitoring (RPM) devices, empowers them to connect actions with outcomes. A hypertensive patient who sees their blood pressure fall after consistent exercise experiences a reinforcing loop of motivation. A heart failure patient who receives alerts about sudden weight gain understands the urgency of calling their provider before it escalates.

RPM expands the impact of data sharing. Devices like scales, glucometers, and blood pressure cuffs transmit readings in real time. Patients can visualize trends, while providers can intervene before complications arise. The act of reviewing data also makes patients more active participants. Instead of waiting passively for the next appointment, they come prepared with observations and questions.

After-visit summaries extend this principle. When patients leave the office with a clear written plan, including medication changes and follow-up steps, they are less likely to forget instructions. Summaries can also be shared with family members, bringing caregivers into the engagement loop. Lara Health integrates RPM and visit data into one interface, creating a single source of truth accessible to both patients and providers.

By democratizing access to information, engagement moves from rhetoric to reality. Patients no longer wonder what is happening in their care—they can see it, track it, and own it.

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Implementation strategy

Implementing patient engagement strategies requires a deliberate approach. The first step is to identify the framework. CCM is often the best entry point because it is reimbursable, structured, and scalable. Once a practice enrolls eligible patients, it can embed communication techniques, shared decision-making templates, and data-sharing workflows into the monthly routine.

Training is critical. Care coordinators and nurses should be skilled in motivational interviewing and empathetic communication. Providers must learn how to integrate shared decision-making into busy visits without feeling rushed. Practices can hold workshops, role-play patient scenarios, and use Lara Health’s guided workflows to reinforce best practices.

Technology infrastructure is another pillar. RPM devices must be set up, data streams monitored, and alerts triaged. Without clear protocols, staff may feel overwhelmed. Practices should define roles: who checks RPM data daily, who responds to abnormal results, and how those responses are documented. Lara Health simplifies this by consolidating communication, RPM, and documentation into one dashboard, ensuring that engagement efforts remain manageable.

Finally, success depends on measuring engagement. Practices should track not just volume (e.g., number of CCM calls completed) but also quality (e.g., number of patient-reported barriers resolved). By turning engagement into a measurable metric, practices can identify strengths, address weaknesses, and continuously improve.

ROI and financial impact

The return on investment (ROI) for patient engagement is both clinical and financial. On the clinical side, engaged patients experience fewer hospitalizations, lower complication rates, and improved quality of life. On the financial side, CCM and RPM reimbursements, combined with reduced penalties and better performance in value-based models, can transform practice revenue.

Consider a cardiology or primary care practice with 1,000 eligible patients. If 500 patients are enrolled in CCM at $60 per month, the practice generates $360,000 annually. If 800 patients enroll, annual revenue rises to $576,000. At full capacity with all 1,000 patients, the practice could generate $720,000 per year. With add-on codes such as CPT 99439 (each additional 20 minutes), revenue can be even higher if staff time justifies it.

When combined with RPM, the impact multiplies. RPM codes such as 99453, 99454, and 99457 provide additional reimbursement for device setup, ongoing monitoring, and interactive communication. For example, if 400 of those CCM patients also participate in RPM, the practice could add $200,000–$300,000 annually in reimbursements. These figures are illustrative, but they show the magnitude of potential revenue when engagement is structured and billable.

Beyond direct reimbursement, engaged patients help practices succeed in value-based contracts. By preventing readmissions, reducing ED visits, and improving HEDIS scores, practices lower total cost of care, which translates into shared savings and bonuses. The financial case for engagement is therefore multi-layered: it drives direct revenue, reduces costs, and strengthens long-term sustainability.

Common pitfalls and how to avoid them

Engagement efforts fail when they become mechanical. Patients quickly notice when staff are reading from scripts or when data is collected without response. Overloading patients with multiple portals or inconsistent messages can also erode trust. Finally, neglecting to act on patient-reported data (such as ignoring RPM alerts) undermines the entire process.

To avoid these pitfalls, practices must balance structure with authenticity. Training staff to communicate empathetically ensures that every patient interaction feels genuine. Consolidating engagement into a single platform prevents fragmentation. Most importantly, practices should close the loop, when patients report concerns, responses must be timely and meaningful. Lara Health supports these safeguards by guiding staff with workflows, automating reminders, and tracking follow-up actions.

Compliance and audit readiness

Patient engagement intersects with compliance because CMS requires documentation of care plans, patient goals, and time spent in CCM activities. During audits, practices must demonstrate both the frequency and quality of interactions. This includes evidence of shared decision-making and proof that care plans are updated regularly.

Manually maintaining this level of documentation can overwhelm staff. Lara Health solves this by automatically logging communications, integrating patient-reported data into care plans, and generating audit-ready reports. Instead of scrambling during audits, practices can demonstrate compliance with a few clicks. Engagement then becomes not only clinically valuable but also administratively sustainable.

Conclusion

Engagement is not a luxury; it is the backbone of effective chronic care. Patients who are invited into their own care journey are more likely to succeed, and practices that systematize engagement improve outcomes, revenue, and compliance. Every conversation, every data point, and every shared decision is an opportunity to strengthen the bond between patient and provider.

Every patient deserves to be more than a passive recipient of care, they deserve to be partners. Book a demo with Lara Health and see how effortless meaningful engagement can be when the right systems are in place.

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Other articles you might like

Integrating CCM and RPM for Better Outcomes

How Chronic Diseases Fit into Value Based Care (VBC)

Advanced Primary Care Management (APCM): A Comprehensive Approach to Preventive Care

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FAQs

What is patient engagement?

Patient engagement is the active involvement of patients in their own healthcare, including communication, shared decision-making, and access to data.

How does CCM improve engagement?

CCM provides structured monthly communication that creates predictable opportunities to involve patients in their care.

Can patients see their RPM data?

Yes, patients can access and review their RPM data, which helps them understand trends and motivates lifestyle changes.

What are common barriers to engagement?

Barriers include poor communication, overwhelming information, and lack of timely response to patient concerns.

How does Lara Health support engagement?

Lara Health integrates communication, RPM data, and care plan tracking into one platform, making engagement simple and compliant.

Sources

CMS. “CY2025 Physician Fee Schedule Final Rule.” 2025.

CMS. “Chronic Care Management Services.” 2025.

AHRQ. “Guide to Patient and Family Engagement in Hospital Quality and Safety.” 2023.

Barry MJ, Edgman-Levitan S. “Shared Decision Making — The Pinnacle of Patient-Centered Care.” New England Journal of Medicine. 2012.