Programs

Care Programs Built Around Your Patients

Every practice has a different mix of patients — some need daily vital sign monitoring, others need a monthly check-in call, others need help managing several medications or recovering from a hospital stay. Rather than offering a single program, we help you launch and run whichever combination of care programs fits your patient population. 

Below is a quick guide to each program we support. 

Remote Patient Monitoring (RPM) 

Connected devices — blood pressure cuffs, glucose meters, pulse oximeters, scales — send real-time readings from a patient’s home to your care team. Best for patients with hypertension, diabetes, heart failure, COPD, or other conditions where daily numbers matter. 

Remote Therapeutic Monitoring (RTM) 

Similar to RPM, but focused on musculoskeletal, respiratory, and therapy adherence data rather than vital signs. Useful for post-surgical recovery, physical therapy, and pain management programs. Chronic Care Management (CCM) Monthly, non-face-to-face care coordination for patients with two or more chronic conditions — phone check-ins, medication review, and care plan updates between visits. 

Principal Care Management (PCM) 

Like CCM, but focused on a single high-risk condition — for example, uncontrolled diabetes or CKD — that needs closer, disease-specific attention than general chronic care management provides. Transitional Care Management (TCM) Structured follow-up in the 30 days after a hospital or facility discharge — the window when readmissions are most likely and most costly to avoid. 

Behavioral Health Integration (BHI) 

Brings mental health screening, coordination, and follow-up into the primary care visit, so behavioral health support doesn’t require a separate referral and wait. Advanced Primary Care Management (APCM) A newer, risk-tiered monthly program for practices delivering comprehensive primary care — bundling many of the coordination tasks above into a single, simplified billing structure. 

Medication Therapy Management (MTM) 

Structured medication reviews for patients on multiple prescriptions, aimed at catching interactions, duplications, and adherence issues before they cause a hospital visit. Especially relevant for pharmacy partners. 

Principal Illness Navigation (PIN) 

Navigation support for patients with a serious, high-risk diagnosis, such as cancer — help scheduling, understanding next steps, and staying connected to their care team.

How They Work Together 

Many of our clinic and pharmacy partners run two or three of these programs side by side — for example, RPM plus CCM for a patient managing diabetes and hypertension, or TCM plus BHI after a hospital discharge with a behavioral health component. We handle the enrollment, documentation, and billing-ready tracking so your team isn’t managing multiple systems to make it work. 

Not sure which programs fit your patient population? Schedule a meeting and we’ll walk through it together