Our Programs

Chronic care management is designed to help patients with two or more chronic conditions.

Remote Patient Monitoring utilizes digital technologies to monitor and capture medical and other health data.

Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other healthcare providers that coordinate to provide high-quality care to their Medicare patients.


Chronic Care Management

Chronic care management is a specific care management service that provides coverage for patients with two or more chronic conditions (A disease or condition is chronic when it lasts a year or more, require ongoing medical attention or limits the activities of daily life.) for a year continuous relationship with their care team.

Examples of chronic conditions: arthritis, diabetes, high blood pressure, clinical depression/anxiety

Services Include : 

  • At least 20 minutes a month of chronic management services
  • Personalized assistance from a dedicated healthcare professional who will work with you to create your care plan
  • Coordination of care between your pharmacy, specialists, testing center, hospitals, and more
  • Phone check-ins between visits to keep you on track
  • Expert assistance with setting and meeting your health goals. 

Available to: Medicare patients and those over 65 years old that don't have Medicare. 

Remote Patient Monitoring

Remote patient monitoring also referred to as remote physiologic monitoring, is the use of digital technologies to monitor and capture medical and other health data from patients and electronically transmit this information to healthcare providers for assessment and, when necessary, recommendations and instructions. The Center for Connected Health Policy (CCHP) notes that RPM programs"...can also help keep people healthy, allow older and disabled individuals to live at home longer and avoid having to move into skilled nursing facilities. RPM can also serve to reduce the number of hospitalizations, readmissions, and lengths of stay in hospital---all of which help improve quality of life and contain costs."

Remote patient monitoring was already gaining popularity before the COVID-19 health crisis. This can be attributed, in part, to the 2020 changes to CPT codes that propelled RPM into the spotlight as one of the most lucrative Medicare care management programs as well as providers increasingly embracing technology to support the health and wellness of their patients.

When the pandemic hit, the value of providing remote patient monitoring services to patients who were expected to reduce travel and direct contact with others became more apparent. The federal government recognized this as well, which is why it expanded Medicare coverage of RPM services from just those with chronic conditions to those with chronic and/or acute conditions, among other changes that supported the increased use of RPM. 

Available to any qualified patient. Medicare covers. Check with your insurance for coverage. 

Accountable Care Organization

ACOs are groups of doctors, hospitals, and other healthcare providers, who come together voluntarily to give coordinated high-quality care to their Medicare patients.

The goal of coordinated care is to ensure that patients get the right care at the right time while avoiding unnecessary duplication of services and preventing medical errors.

Our practice partners with Aledade who provides tools and support to achieve our goals for quality improvement. 

More About Accountable Care Organizations