Our RPM program connects your highest-risk patients to your practice using FDA-cleared, cellular-enabled medical devices. We take the friction out of remote monitoring by handling the logistics, the software, and the daily triage.

• What We Offer: We supply cellular blood pressure cuffs, weight scales, and glucometers directly to your patients' homes. No Wi-Fi pairing or smartphone apps required—patients simply take their vitals, and the data automatically transmits to our secure dashboard.

• What Our Nurses Do: Our clinical team monitors incoming vitals daily, escalates abnormal readings to your providers based on your custom protocols, and logs the required clinical time (CPT 99457 & 99458).

• The Clinic Benefit: Reduced emergency room readmissions, passive device reimbursement (CPT 99454), and better patient compliance—all with zero upfront device costs required from your clinic.

Managing patients with two or more chronic conditions requires consistent, time-consuming follow-up. Our CCM program ensures your patients stay on track with their care plans between office visits.

• What We Offer: A dedicated team of clinical staff who call your patients every single month to check on their health, assist with medication refills, and coordinate care with specialists.

• What Our Nurses Do: We perform the heavy lifting of the monthly telephonic outreach, ensuring the CMS-required 20 minutes of clinical staff time (CPT 99490) is met, properly documented, and automatically formatted into an audit-ready billing report for your team.

• The Clinic Benefit: You unlock significant new Medicare revenue streams while providing concierge-level care to your seniors, without your internal staff having to make hundreds of phone calls each month.

When your patients face severe exacerbations of their chronic conditions, 20 minutes a month isn't enough. We scale our clinical time to meet the needs of your most complex cases.

• What We Offer: Advanced clinical monitoring and extended care coordination for patients requiring moderate-to-high medical decision-making.

• What Our Nurses Do: We provide 60+ minutes of comprehensive clinical staff time (CPT 99487 & 99489), adjusting care plans under your provider's supervision, managing transitions of care, and stabilizing patients to prevent hospitalizations.

• The Clinic Benefit: Safe, closely monitored management of your sickest patients, fully documented for complex CMS reimbursement.

Continuum Care Management’s platform is built to grow with your practice. We offer specialized tracks to capture single-condition patients and address the mental health needs of your population.

• Principal Care Management (PCM): For patients with a single, high-risk chronic condition (like newly diagnosed heart failure or severe asthma) that requires intensive, specialized focus for 3 to 6 months.

• Behavioral Health Integration (BHI): We provide the monthly clinical staff time needed to support patients diagnosed with depression, anxiety, or other behavioral health conditions, ensuring they are adhering to their therapeutic and pharmacological plans.