Chronic Care Management
Monthly non-face-to-face clinical management for patients with two or more chronic conditions. Care planning, medication reconciliation, coordination across the care team — all documented, coded and billable.
- Comprehensive care planPatient-centered, problem-list driven, updated quarterly.
- Medication reconciliationEvery contact — prevents the most common preventable harm.
- PCP & specialist coordinationClosed-loop referrals, results follow-up, transition handoffs.
- SDOH screening & resourcingIdentify and address the non-clinical drivers of outcomes.
Remote Patient Monitoring
Daily physiologic data capture — blood pressure, weight, oxygen saturation, glucose — with clinical thresholds, escalation pathways, and intervention before the patient reaches the ER.
- Device fulfillment & onboardingCellular devices shipped to the patient — no Wi-Fi setup required.
- Threshold-based clinical alertsDisease-specific limits, not one-size-fits-all defaults.
- Daily clinical reviewPatterns matter — not just outliers. Our team reviews trends.
- Documentation for billing16-of-30-day requirement tracked automatically.
Transitional Care Management
Post-discharge coordination within 7 and 14 days to prevent readmissions. Medication reconciliation, follow-up scheduling, and patient education bridging the hospital-to-home transition.
- 48-hour interactive contactTelephone or in-person within two business days of discharge.
- Discharge med recReconcile hospital med list against home regimen — catch errors early.
- Follow-up visit schedulingWithin 7 days for high complexity, 14 for moderate.
- Readmission-risk monitoringActive surveillance through the 30-day window.
Advanced Primary Care Management
The evolution of CCM for high-complexity patients — 24/7 access, care team coordination, behavioral health integration, and comprehensive care plans for your highest-need population.
- 24/7 access to the care teamAfter-hours clinical triage, not a call-back voicemail.
- Behavioral health integrationScreening, brief intervention, warm handoff to BH partners.
- Quarterly care plan reviewWith patient, caregiver and care team — kept current.
- Tier-based billing modelThree risk strata, three payment levels — aligned to acuity.
Remote Therapeutic Monitoring
Non-physiologic monitoring for musculoskeletal and respiratory patients — pain scores, functional status, medication adherence and therapy program compliance between visits.
- Validated PROMsPROMIS-PF, NPRS, KOOS/HOOS — measurement that maps to ASM.
- Adherence trackingInhaler technique, PT compliance, sleep apnea CPAP usage.
- Pre/post-op pathwaysBuilt for joint replacement, spine surgery, pulmonary rehab.
- Clinical interpretationTrends triaged by our team — not dumped on your inbox.
Principal Care Management
Single-condition care management for patients with one complex chronic condition requiring specialist-level oversight — disease-specific plans, monthly management, outcome tracking.
- Single-condition focusBuilt for the specialist managing one expensive disease.
- Disease-specific care planTargeted to your specialty's evidence base and pathways.
- Coordination with PCPClosed-loop — the patient's PCP stays in the loop.
- Outcome-aligned billingTracks the encounters and time CMS requires for reimbursement.
Built for whoever runs the program.
ACOs
Move quality measures and shared-savings performance across attributed lives.
Hospitals & Health Systems
Cut 30-day readmissions, bridge discharge to home, support service-line ACOs.
Assisted Living & Memory Care
Monthly CCM with RPM data feeds — protect residents, reduce liability.
Specialty Practices
Cardiology, orthopedics, pulmonology — disease-specific PCM and RTM revenue.
Primary Care & FQHC
APCM and CCM infrastructure without hiring an internal care team.
ASM-Enrolled Specialists
Mandatory cardiology and LBP program — ±9% Part B revenue at stake.
Let us show you the difference.
One conversation. No commitment. Just clarity on what's possible for your practice — and a clear plan before ASM launches in January 2027.