A chronic care management program to help you improve patient care and meet your quality metrics

Finally implement a successful CCM program

metrics

Manage and improve quality metrics

We’ll help improve documentation and quality metrics by establishing a baseline via our risk assessments, then initiate a proactive care plan for your enrolled patient.

emr

Get real-time updates directly into your EMR

There is never a need to learn a new system. Our documentation will be in your EMR shortly after we speak with your patients, so you always have the most current information.

revenue

Generate more
revenue

By implementing our remote chronic care management program, you’ll maintain contact with patients on a monthly basis AND generate revenue for your organization for each encounter we conduct.

What you can expect from our CCM program

enrollment

Increased patient enrollment

We’ll reach out to your Medicare patients with two or more chronic conditions to explain the benefits of the program. We enroll over 70% of eligible patients and achieve patient retention rates over 90% month to month.

support

More time for staff to focus on face-to-face support

We’re here to supplement the care your staff provides–not compete with it. We work as an extension of your clinic to provide the additional resources needed to enroll patients and conduct monthly encounters, allowing your staff to focus on the tasks they were trained to do.

encounters

Monthly encounters with patients

Your dedicated care team will strive to speak with enrolled patients every month, tailoring conversations to the unique needs of your patients and providing an experience they can look forward to.

care-plans

Care plans without a trip to the clinic

Our certified clinicians are able to provide customized care plans to your patients in the comfort of their own home.

experience

A seamless experience for your patients

We integrate into your existing workflow, act as a seamless extension of your staff, and use local phone numbers with a familiar caller ID.

systems

No need to learn a
new system

Our advanced technology is designed to integrate directly with your EMR system. With us, you get the real-time insights you need to provide better patient care—without spending time or money implementing a new platform.

Generate extra revenue and add remote staff
at no added cost to you

savings

There are no setup costs or out-of-pocket expenses for your clinic.

setup

We’ll handle everything, from setup and enrollment to assessments and reporting and beyond.

revenue

Generate an average of $200,000+ per year net revenue (for clinics of 1,000 patients or more).

Getting started with us is easy

All you need to do:

list

Provide a list of your eligible Medicare patients

We’ll reach out to your Medicare patients suffering from two or more chronic conditions and work to enroll them in the CCM program.

emr

Grant us remote access to your EMR

Our proprietary workflow integrates with your EMR to keep your records updated with all communication and patient data provided on your behalf.

champion

Assign an internal champion

Assign someone from your team as the primary point of contact for periodic program updates.

We’ll do the rest

• Confirm patient eligibility and build out cohorts
• Schedule and conduct orientation sessions with your staff
• Create marketing materials
• Build out clinical pathway and care templates
• Craft encounter note summary templates
• Confirm program update process

• Send out welcome letters to patients
• Conduct EMR assessment
• Coordinate patient introductions
• Obtain and document patient consent
• Ensure compliance standards are met

• Connect with patient caregivers
• Complete intake assessment
• Conduct monthly patient calls, assessments, and pathways
• Review and update patient goals
• Carry out intervention plans
• Coordinate in-person patient appointments
• Provide referral assistance as needed

• Generate and upload care plans to EMR
• Mail care plans to patient
• Upload post-encounter summary notes
• Submit monthly risk level report
• Generate productivity reports
• Compile monthly billing reports

elderly man speaking to remote patient care company
They listened to what I needed, they were extremely receptive to adjusting their delivery to meet my needs, and they were very interested in elevating the level of education that they gave my patients.”
gordon wilhoit
Dr. Gordon Wilhoit,
Primary Care Physician and Managing Partner
Value Health Partners

Complete patient care in 3 simple steps

patient-list

You provide
the patients

Provide us with your patient list and we’ll handle the rest.

contact

We contact
and enroll

We contact all eligible patients and work to enroll them in the CCM program.

care

Complete care experience

We’ll conduct regular encounters and report back, providing patients the support they need to stay healthy.

“I love that this program is available and I’m grateful that someone calls to check in on me.”

– Deborah, 69

Learn how to get started risk-free