Key Takeaways from Our Webinar with NextGen Healthcare: Rethinking the Future of Longitudinal Care

Healthcare is changing, and so is the way organizations think about caring for patients with chronic conditions. 

That was the focus of our recent webinar, “Rethinking Chronic Care: Building the Next Generation of Longitudinal Care Models,” where Amy Garcia, Vice President of Product Management for Value-Based Care & Government Reporting at NextGen Healthcare, joined CareHarmony CEO and co-founder Gokul Mohan for a discussion on the forces reshaping chronic care management. Together, they explored how healthcare organizations can improve patient outcomes, reduce provider burden, and prepare for the continued evolution of value-based care. 

While the conversation covered topics ranging from CMS policy to artificial intelligence, one message remained consistent throughout the discussion: better outcomes don’t happen during a single office visit—they’re built through ongoing engagement and support between visits.

If you couldn’t join us live, here are five of the biggest takeaways from the conversation.

1. Healthcare Is Facing a New Reality

The discussion began by examining why chronic care management has become such an urgent priority for healthcare organizations. 

According to the Centers for Medicare & Medicaid Services (CMS), chronic and mental health conditions account for approximately 90% of the nation’s annual healthcare expenditures. At the same time, research published in The American Journal of Medicine reports that nearly three out of four U.S. adults are living with at least one chronic condition. Combined with an aging Medicare population and growing physician shortages, these trends are creating unprecedented demand for healthcare services. 

As Gokul explained during the webinar, these challenges aren’t happening independently. Healthcare organizations are caring for increasingly complex patient populations while also navigating workforce shortages, financial pressures, and the continued transition to value-based care. The traditional model of relying primarily on office visits is becoming more difficult to sustain, making it increasingly important to find new ways to support patients between appointments. 

Rather than viewing these changes as separate challenges, healthcare leaders should recognize them as part of a broader transformation in how care is delivered.

2. Longitudinal Care Is About What Happens Between Visits

One of the central themes of the webinar was the shift from episodic care to longitudinal care. 

For decades, healthcare has focused on treating patients during scheduled office visits. But chronic diseases don’t stop when patients leave the clinic. Managing diabetes, heart disease, hypertension, COPD, and other chronic conditions depends on what happens every day between appointments—whether patients are taking medications as prescribed, monitoring symptoms, following care plans, and receiving timely support when concerns arise. 

As Gokul noted during the discussion, improving outcomes requires healthcare organizations to think beyond individual encounters and focus on maintaining continuous relationships with patients throughout their healthcare journey. 

That perspective is changing how organizations approach care management. Instead of asking how to improve the next office visit, they’re asking how to keep patients engaged throughout the year, identify risks earlier, and intervene before small problems become avoidable emergency department visits or hospitalizations. 

3. CMS Programs Reflect a Bigger Shift in Healthcare

The discussion also explored how CMS has steadily expanded opportunities for care management over the past decade. Rather than introducing isolated programs, CMS has consistently built on a broader vision of supporting patients beyond the traditional office visit.

Chronic Care Management (CCM) laid the foundation by supporting patients living with multiple chronic conditions. Principal Care Management (PCM) expanded care management for patients with a single complex condition, while Remote Patient Monitoring (RPM) brought connected devices and physiologic data into the care continuum. More recently, Advanced Primary Care Management (APCM) and the ACCESS Model have continued that evolution by reinforcing the importance of coordinated, proactive, and longitudinal care. While each program has its own purpose and requirements, they all reflect the same shift toward helping providers deliver continuous support throughout a patient’s healthcare journey.

One insight that resonated throughout the discussion was that organizations often spend too much time deciding which program to implement first. As Gokul explained, a better starting point is determining whether they have the operational capabilities needed to deliver longitudinal care successfully. Organizations that build strong care management infrastructure are better prepared to adapt as new payment models and CMS initiatives emerge because they already have the workflows, technology, and care teams needed to support patients over time.

Rather than chasing individual reimbursement opportunities, healthcare leaders should focus on building a sustainable care strategy that can evolve alongside the changing healthcare landscape.

4. Successful Organizations Focus on Strategy, Not Just Reimbursement

Another important takeaway from the webinar was that successful care management programs aren’t built around billing codes—they’re built around patients. 

According to Gokul, organizations that consistently achieve strong clinical and operational results share several common characteristics. They take a population health approach to identifying patients who will benefit most from care management services, establish standardized workflows, measure meaningful clinical and operational outcomes, and invest in the infrastructure needed to support patients over time. 

Perhaps most importantly, they view care management as an extension of clinical care rather than a standalone initiative. 

That distinction matters because organizations that focus solely on reimbursement often struggle to scale their programs. Those that prioritize patient engagement, care coordination, and operational excellence are better positioned to improve outcomes while also building sustainable programs that can adapt as healthcare continues to evolve.

5. Technology Should Help Care Teams Deliver Better Care

The webinar concluded with a discussion about technology and the growing role artificial intelligence will play in the future of chronic care management. 

Rather than replacing clinicians, both speakers emphasized that technology should reduce administrative burden and help care teams focus their time where it’s needed most. Electronic health records, population health platforms, and AI-powered tools all have an important role to play, but only when they’re integrated into thoughtful clinical workflows that support—not complicate—the delivery of care. 

Gokul discussed how AI can help organizations identify patients who may need additional support, prioritize outreach efforts, and automate routine administrative tasks. When implemented effectively, these technologies allow care teams to spend more time engaging patients and less time navigating manual processes, ultimately strengthening the relationship between providers and the patients they serve. 

Looking Ahead 

As healthcare continues to evolve, the organizations that succeed will be those that recognize longitudinal care as more than another reimbursement opportunity. It is becoming a foundational capability for improving outcomes, supporting clinicians, and preparing for the future of value-based care. 

That was perhaps the most important message from our conversation with NextGen Healthcare. While CMS programs, AI, and new technologies will continue to shape the healthcare landscape, lasting success will depend on an organization’s ability to build meaningful relationships with patients beyond the walls of the clinic. 

Thank you to everyone who joined us for the discussion. If you missed the live webinar, we hope these takeaways provide a helpful overview of the key themes and encourage you to think differently about how longitudinal care can support your patients, providers, and organization.