Caregiver & Family Engagement

PURPOSE: This SOP guides Care Coaches on how to identify, engage, and coordinate with caregivers and family members within the CCM and Patient Advocacy programs — improving patient outcomes, increasing engagement, and ensuring clean billing for the 20-minute CCM threshold.

Section 1: Defining a Caregiver in CCM Context

⚠️ Compliance Note: The Compliance Team conducts periodic reviews to ensure all patients receive appropriate care. We ask all staff to uphold the highest standard of integrity in documenting every activity accurately and completely—to avoid immediate termination.

⚠️ Compliance Note: A caregiver cannot be engaged until the patient has given documented authorization. Never share PHI with a caregiver without verification that consent is on file.

  • A caregiver, for the purposes of CCM and Patient Advocacy, is any authorized individual who assists the patient in managing their health — including scheduling, medications, transportation, emotional support, or

  • •       Spouse, adult child, or domestic partner

    •       Parent or sibling actively involved in care decisions

    •       Friend or neighbor identified by the patient as a support person

    •       Professional home health aide or personal care attendant

    •       Legal guardian or healthcare proxy (documented in chart)

  • 1.     Confirm existing authorization in the patient chart before the call.

    2.     If no authorization exists, ask the patient directly: "Is there a family member or caregiver you'd like us to be able to speak with about your care?"

    3.     If yes, obtain verbal consent during the call and document it with date, time, and staff name.

    Route to formal written authorization per your organization's consent process within 30 days

Section 2: Identifying and Documenting the Caregiver

  • •       Patient has not answered 2+ consecutive outreach attempts

    •       A family member or third party answers the patient's phone

    •       Patient mentions difficulty managing tasks independently

    •       SDOH screen reveals unmet needs suggesting reliance on others

    •       Post-discharge contact — caregiver is often present at home

    •       Cognitive or functional decline is noted in the chart or call

  • On a call with the patient:

    "Is there someone — a family member, a friend, or anyone else — who helps you manage your health or your appointments? We'd love to include them in the loop if you're comfortable with that."

    When a family member answers the phone:

    "Hi, I'm [Name], a Care Coach from [Practice]. I was hoping to reach [Patient Name] about their care. Are you someone who helps them with their health? I'd love to learn a little more about how we can best support them as a team."

  • •       Caregiver name and relationship

    •       Preferred contact method and best times to reach

    •       Authorization status (verbal/written) with date and documenting staff name

    •       Any clinical updates shared with caregiver — documented as care coordination time

    BILLING TIP:  Caregiver communication is billable CCM care coordination time. Always timestamp the entry and include your name and role.

Section 3: Caregiver Engagement Pathways

  • When a patient consistently does not engage directly, the caregiver becomes the primary point of contact for non-clinical updates and logistical coordination. This does not replace the patient relationship — it supplements it.

     

    1.     Introduce yourself and the program in plain language.

    2.     Explain your role: monitoring the care plan, advocating for the patient, and flagging issues to the provider.

    3.     Ask the caregiver about their observations — they often have critical clinical information the patient doesn't report.

    4.     Give the caregiver one clear action item or update per call to keep them engaged.

    5.     Document all caregiver communication as care coordination. Include duration.

  • 3.2  When the Caregiver Screens Patient Calls

    If a caregiver is acting as a gatekeeper and limiting Care Coach access to the patient:

    Compliance Note:  Do not bypass the caregiver — work with them, not around them. Antagonizing a caregiver will permanently close access to the patient.

    •       Acknowledge their role: "I can see how much you care about [Patient Name] — that's exactly the kind of support we want to work with."

    •       Educate the caregiver on the program value: "Our goal is to make your job easier, not to add to your plate."

    •       Offer to schedule calls at a time that works for both the patient and caregiver.

    •       If access remains blocked after two attempts, escalate to your supervisor for care team discussion.

  • Caregiver burnout is a major risk factor for patient health deterioration. The Patient Advocacy service should proactively screen for caregiver stress.

     Caregiver Screening Questions:

    •       "How are you holding up? Caring for someone is a lot of work."

    •       "Do you have enough support yourself — anyone helping you?"

    •       "Are there any services that would make things easier for you both?"

    Compliance Note: If a caregiver expresses significant burnout or inability to continue in the role, escalate to your supervisor and flag for social work referral. Document the concern and action taken.

Section 4: Advocacy Scripts for Caregiver Calls

  • "Hi [Caregiver Name], my name is [Coach] and I'm a Care Coach with [Practice]. I support [Patient Name] through our Chronic Care Management program. We help manage their care between visits and advocate for them on things like insurance, medications, and specialist access. I'd love to include you as part of the care team — with [Patient Name]'s permission. Do you have a few minutes?"

  • "Hi [Caregiver Name], this is [Coach]. I'm calling with a quick update on [Patient Name]. Their care plan is current and there are no urgent concerns today. I did want to check in with you — have you noticed anything different with their health lately? Sometimes the people closest to a patient see things first."

  • Compliance Note: When the patient won't engage but the caregiver will:

    "I want to be transparent with you — we've been having trouble reaching [Patient Name] directly, and I want to make sure their care doesn't fall through the cracks. Would you be comfortable helping us stay connected? I'll keep calls brief and only reach out when there's something important to address."

  • "Thank you for telling me that. This is exactly the kind of thing I can help with. I'm going to look into [the prior auth / medication cost / the referral delay] today and follow up with you within 48 hours. You don't need to do anything on your end."

  • "Hi [Caregiver Name], I saw that [Patient Name] was recently in the hospital and is back home now. I'm calling to make sure the transition goes smoothly. I want to confirm medications are correct, follow-up appointments are scheduled, and that you both know exactly who to call if anything changes. Can we go through a quick checklist together?"

  • "Before I let you go — is there anything that's been hard to manage lately? A lot of caregivers run into issues with insurance, medications, appointments, or just needing more support, and don't realize those are things we can actually help with. We're here for all of it."

    Compliance Note: This closing question is mandatory on every caregiver call. It is the single most effective way to surface unmet advocacy needs.

Questions?

Contact Resource & Tools Directors Amanda Lewis or Chrissy Knotts at Support@Mxviii.com if the SOP or Guide you need is missing.

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