CMS should test behavior-informed approaches to chronic care

Optimal chronic care management depends on influencing what people do every day. Chronic conditions remain widespread, and the prevalence has increased significantly among younger adults in the United States. In 2023, approximately 76.4% of noninstitutionalized adults reported at least one of 12 selected conditions. Many of the most prevalent and costly conditions, such as hypertension, cardiovascular disease, obesity, and diabetes, are directly influenced by modifiable behavioral risks, environmental exposures, social conditions, and other clinical and biological factors. The U.S. healthcare system is poorly designed to alter this trajectory. Without payment and delivery models that support continuous patient engagement and behavior change, CMS innovation models will struggle to achieve their full clinical and economic potential.

The challenge is most evident among patients with coexisting chronic medical and behavioral health conditions. Managing chronic medical and behavioral conditions depends on driving behavior change. Sustained behavior change requires continuous reinforcement, personalized guidance, and timely support delivered within patients’ daily lives, not only during clinical encounters. The change mechanism should respond to emotional and social context and be tailored to reinforce positive behaviors, including encouragement for people experiencing vulnerability or isolation.

One example comes from a 2020 GoMo Health white paper describing The Heart House Cardiac Concierge Care Program, which was a behavioral support model for patients with congestive heart failure. Patients received a structured behavior-change intervention through personalized text-based messaging, caregiver participation, symptom monitoring, and rapid escalation pathways for emerging clinical concerns, with timely guidance on medication adherence, diet, exercise, stress, smoking cessation and emotional coping integrated into their existing routines. The program reported favorable pre- and post-program outcomes. Participants self-reported a 98% medication adherence rate for heart-failure medication, and 43% of respondents who completed smoking surveys reported decreasing their tobacco use. The report also stated that the observed 90-day hospital readmission rate declined from 19% to 12%, while one-year readmissions fell from 44% to 19%.

Effective engagement is not simply about increasing communication frequency. Behavioral science research shows that individuals are more likely to adopt and sustain healthy behaviors when interventions address motivation, self-efficacy, social support and habit formation. Behavior-informed care applies behavioral science principles to personalize support, including positive reinforcement, timely prompts, caregiver involvement, and progressive goal setting, to help individuals translate clinical recommendations into daily actions. Rather than serving as passive reminders, these interventions create an ongoing support structure that helps patients navigate barriers, build confidence, and sustain behavior change over time.

Michael S. Barr, M.D., MBA, is a member of the GoMo Health Healthcare Innovation Advisory Board and president and founder of Medis LLC.