Chronic Care Management

Integrated Chronic Care Management with Remote Patient Monitoring (RPM)

Enhancing Continuity.

Improving Outcomes.

Advancing Value-Based Care.

Effective management of chronic disease requires proactive engagement, real-time insight, and seamless coordination across care teams. Our Chronic Care Management (CCM) program — fully supported by Remote Patient Monitoring (RPM) — delivers a clinically validated, scalable solution designed to strengthen patient outcomes, reduce avoidable utilization, and support performance in value-based care models.

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Remote Patient Monitoring (RPM)

Continuous Insight.
Early Intervention.
Measurable Impact.

Our Remote Patient Monitoring (RPM) service enables healthcare organizations to extend care beyond the clinic and into patients’ homes — transforming chronic disease management through continuous data, proactive intervention, and improved patient engagement.
We deliver a fully managed RPM program that integrates seamlessly with your clinical operations, supporting both patient outcomes and organizational performance under value-based care models.

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Core CCM & RPM Capabilities

Our turnkey platform combines technology, staffing, and data integration to streamline chronic care across diverse care settings.

Clinical Operations
* RN-led care coordination with evidence-based care plans
* Monthly patient outreach and medication reconciliation
* Escalation protocols aligned with physician oversight
* Remote Patient Monitoring (RPM)
* Daily data capture for vitals including BP, glucose, weight, SpO₂, and heart rate
* Automated alerts and clinical triage workflows
* Device logistics and patient onboarding fully managed

Technology Integration
* EHR interoperability for seamless data exchange
* Secure HIPAA-compliant communications and reporting
* Population-level dashboards for cohort management

Patient Engagement & Education
* Continuous communication and reinforcement of care plans
* Personalized feedback to support adherence and self-management
* Real-time interventions that reduce ED visits and readmissions

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Benefits

For Health Systems & Physician Groups
* Extend clinical capacity through RN-led chronic care coordination
* Improve HEDIS and STAR measures by addressing care gaps
* Reduce readmissions and ED utilization
* Enhance patient satisfaction and engagement scores

For Population Health & ACOs
* Real-time data to support risk stratification and predictive modeling
* Scalable infrastructure for managing high-cost, high-risk populations
* Actionable analytics to support performance-based contracts

For Insurers & Managed Care Organizations
* Improved outcomes across chronic cohorts
* Reduced total cost of care through early intervention
* Data transparency and outcomes reporting for quality initiatives

Measured Results
Organizations consistently report:
* 25–40% reduction in readmissions among high-risk populations
* Improved blood pressure and glucose control within 90 days
* Higher patient engagement and adherence rates
* Documented cost savings tied to early intervention