Case Study

Primary Care Practice Generates $164/ho with ChronicCareIQ

THE OBJECTIVE:

To Increase Provider Workload & Medicare Reimbursement, While Eliminating Manual Processes

As patient demand increased and local access to care remained limited, Better Weighs needed to maximize clinical impact without overextending providers.

Key challenges included:

Managing CCM patients using manual, color-coded Excel spreadsheets
Limited visibility into patient needs between visits
Increasing provider workloads with limited time for care management tasks
The need to optimize Medicare reimbursement while supporting long-term condition management

The practice sought to operationalize and scale its chronic care programs, improve efficiency, and support a transition toward value-based care.

Provider Background

Better Weighs to Better Health is a growing primary and urgent care practice in Athens, Alabama, one of the state’s fastest-expanding cities. The practice consists of one physician and three nurse practitioners and serves a rapidly growing patient population of 5,000 patients (and counting.)

Led by Dr. Melissa Gray and Kristy Townsend, LPN, the practice emphasizes preventative and longitudinal care. In addition to primary and urgent care, Better Weighs offers wellness coaching, weight management, and hormone and IV therapies, with a strong focus on helping patients manage chronic conditions such as diabetes and hypertension

THE SOLUTION:

Implementing ChronicCareIQ Replaced Manual Tracking With An Integrated, Automated CCM/RPM Platform

ChronicCareIQ enabled the practice to:

- Automatically surfaced the highest-need patients each day
- Enabled care teams to begin work immediately using overnight and morning data
- Centralized documentation, outreach tracking, and time capture
- Supported continuous patient communication outside of office visits
- Branded its CCM program as “primary care management” to improve patient understanding and enrollment

The platform enabled Better Weighs to deliver proactive, continuous care while reducing administrative burden on clinical staff.

“Our program has an incredible impact on patients, their families, and our office staff. What we do takes multiple tasks off of the entire clinical floor team on a daily basis.”
— Kristy Townsend, LPN, CCM Program Director

Patients Enrolled

Patients Qualified
For Billing

0 %

Per Hour Generated

$ 0

Practice Results:

80% increase in MIPS scores
Improved identification of previously undocumented chronic conditions
Greater care team efficiency, allowing providers more time for sick visits, lab review, diagnostics, and charting
Expanded capacity to manage high-maintenance patients through dedicated care management teams
Improved readiness for value-based care models

“Today’s landscape means providers are expected to see upward of 15 to 20 patients a day, so they just don’t have the time to do the things that care management teams can when supported by technology.”