Diseases that require chronic disease management like Diabetes, Heart Failure, and Chronic Obstructive Pulmonary Disease (COPD) pose a massive challenge to healthcare systems. In the US, chronic conditions account for a staggering 90% of the nation’s $4.9 trillion in annual health care expenditures. In Canada, roughly 44% of adults have at least one chronic disease.

The key to tackling this growing issue isn’t just better treatments—it’s better management through continuous, proactive patient engagement. Healthcare providers who use proactive care methods, such as automated patient messaging, don’t just improve patient health; they also create more efficient clinic operations and unlock significant revenue streams through programs like Chronic Care Management.
This is where ACM Messenger becomes a game-changer. It’s a powerful tool for engaging, identifying, and reporting on high-risk chronic disease patients, directly aligning with the goals of high-quality, reimbursable chronic care.

Engage: Driving Behaviour Change with Personalized Messaging

Engaging chronic disease patients requires continuous, low-friction communication. Automated messaging, particularly via text, meets patients where they are—on their phones—making it an inclusive solution, even for older adults who may struggle with complex apps. Text reminders and notifications have been shown to increase the odds of patients sticking to their medication programs.

ACM Messenger provides the automated infrastructure to implement specific, high-impact engagement strategies for common chronic conditions:

• Diabetes: Poor medication adherence is a major risk for complications. ACM Messenger can send automated, personalized medication reminders (e.g., “Time for your insulin dose and to check your glucose!”) and appointment reminders for crucial eye exams or podiatry appointments. Consistent reminders promote adherence and help patients avoid serious complications like kidney failure and blindness, which are associated with the $413 billion annual cost of diabetes in the US.

• Heart Failure (HF): Weight changes and diet are vital to HF management. Automated check-ins can prompt patients to report their weight daily. A message could read: “Please reply with your current weight. Contact us immediately if you’ve gained 3 or more pounds since yesterday.” This proactive monitoring allows care teams to intervene before a minor issue escalates into a serious health crisis or emergency department visit.

• COPD: Timely interventions for respiratory symptoms can prevent hospitalization. Automated messages can prompt patients to report their symptoms, like “Are you experiencing increased shortness of breath or a change in mucus colour today? Reply YES or NO.” Based on their response, the system can provide tailored educational content or immediately alert clinical staff for a follow-up call.

By automating these personalized nudges, ACM Messenger ensures patients feel continuously supported without overwhelming clinical staff, freeing up valuable time for high-touch care that truly requires human attention.

Identify: Finding and Prioritizing High-Risk Patients

The sheer volume of patients with chronic conditions—three in four American adults have at least one—makes manual oversight impossible. A critical function of a proactive care platform is to filter and prioritize who needs an immediate, in-person touchpoint.

ACM Messenger uses communication to gather real-time data from patients, moving beyond simple one-way reminders.

• Symptom Check-ins and Red Flags: The platform can categorize patient responses to identify those who are veering off their care plan. For instance, a diabetic patient who repeatedly misses lab appointments or a heart failure patient who reports a concerning weight gain can be automatically flagged as high-risk.

• Non-Adherence Detection: By integrating with a practice’s Electronic Medical Record (EMR) data, ACM Messenger can pinpoint “dormant patients”—those with chronic conditions who have missed preventative screenings (like a COPD annual flu shot) or are overdue for a follow-up. Automated messages can then initiate a reactivation campaign to re-engage them in care.

Administrative Efficiency: This process streamlines patient flow by directing administrative staff to focus their manual follow-up calls only on the non-responsive or high-risk individuals, instead of making countless blind calls. This capability is vital to reducing staff burnout while maximizing care coverage.

Report: Documenting for Compliance and Reimbursement

Effective chronic disease management is recognized and financially supported by major payers, including Medicare in the US, through programs like Chronic Care Management (CCM). This is where the ability to report and document is not just an administrative task—it’s a direct path to revenue.

CCM allows providers to bill for non-face-to-face services provided to Medicare patients with two or more chronic conditions. Automated messaging is a core activity in CCM, and ACM Messenger helps clinical staff meet the time-based requirements for reimbursement.

ACM Messenger directly contributes to this billable time by:

• Time Tracking: Every message sent, two-way interaction, and educational resource delivered counts toward the non-face-to-face time required by CCM codes. The platform automatically logs these activities, creating an auditable record of time spent managing the patient’s care plan.

• Care Coordination Documentation: The platform’s ability to document the monitoring of symptoms (e.g., HF weight checks, COPD symptom status) establishes the “moderate or high complexity medical decision making” necessary to qualify for the higher-reimbursing complex CCM codes, such as CPT 99487.

Reducing Readmissions: Most importantly, proactive care through digital engagement significantly reduces preventable hospital readmissions. Since engaged patients are more likely to follow treatment and medication plans, they experience fewer complications. This not only improves patient outcomes but also helps providers avoid penalties and succeed in value-based payment models that reward quality and efficiency.

The Future of Proactive Care

The burden of chronic disease—both in patient suffering and financial cost—demands a fundamental shift from reactive to proactive care. ACM Messenger provides the crucial link between the clinic and the patient, automating the essential communication needed to manage complex, long-term conditions like diabetes, heart failure, and COPD. 

By integrating seamless patient engagement, smart high-risk patient identification, and compliant reporting, the platform drives better health outcomes, streamlines clinic workflow, and secures legitimate reimbursement for the valuable care coordination that happens outside the exam room.