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Hospital Staff

Advantages of Care Management Services

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Our care management services are packed with gold standard innovation and validated behavioral, clinical, and educational principals to increase patient engagement and boost their knowledge, skills, and confidence in managing their care.


Following the precise guidelines set forth by the Affordable Care Act and Medicare, we deliver outstanding care and care management services

Care Coach

Following each Doctor's care instructions, our Care Coaches provide care coordination services in a systematic way to supplement regular doctor office visits. 

Our Care Coaches utilize proven clinical, behavioral, and educational principles along with advanced communication skills training to ensure better interaction with patients and providers.

Managing chronic diseases requires a fundamental shift in thinking, from a reactive model - treating patients mainly when they become sick or enter your exam room - to a proactive model focused on prevention and wellness before sickness occurs. This approach requires meaningful communication to patients beyond your exam room - and on a regular schedule.

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Advantages to the Patient

Among a multitude of benefits, some understood and some yet realized, your patients will:

  • Gain a higher level of engagement in their own healthcare and medical records; 

  • Gain a higher level of trust for your practice brand loyalty;

  • Gain 24/7 access for non-emergency contact;

  • Reduce avoidable visits to urgent-care or emergency room settings;

  • Access via telephone, smart phones, tablets, laptops, desktop computers or other online devices through HIPAA compliant patient portal; 

  • Have access to electronic medical records including other critical customer data.

24/7 chronic care centers will:

  • Provide a turnkey enterprise solution for Chronic Care Management.

  • Provide state-of-the-art technology, infrastructure, and staffing.

  • Provide an immediate solution, without risking your capital, staff, and time. 

  • Identify and enroll eligible patients.

  • Ensure 24/7 access to non-emergency care intervention.

  • Provide each patient access to an easy-to-use online patient web portal and mobile application.

  • Support your patients, and your practice with compliant care management services.

  • Manage and coordinate care among all of the patient's providers as specified by CMS.

  • Provide certified electronic health records (EHR) transferring patient data through your EHR to populate patient profiles with records from your practice.

  • Prepare a comprehensive care-plan for every patient, including updates as necessary.

  • Work directly with your practice staff to appropriately bill Medicare for CCM reimbursement.

  • Help coordinate your practice’s calendar to fill open appointments with eligible patients.

See the Difference

Discover the most comprehensive solutions for chronic care management, MACRA, and beyond...

Use our online contact form and schedule your personal online tour.

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Care Centers

Expand your reach beyond your daily schedule. Our state-of-the-art Care Centers deliver the gold standard for non-face-to-face interactions.

Our staff is available to assist with any acute or chronic care needs under direct supervision; whether by telephone or any online device. Our services are HIPAA compliant and always include the patient's electronic care plan.

Each interaction is captured, recorded, and stored to deliver accurate and precise audit capability. 


All recorded data is integrated into your practice records allowing a 360 degree view of every patient, anytime, and from anywhere.

Advantages to the Provider



  • Increase RAF and STAR ratings while complying with HIPPA, MACRA and MIPS

  • Minimum CAPEX (capital expense)

  • NO Workflow Interruption

  • Trained clinical staff

  • Technology Platform & Integration

  • Covers everything from EHR integration to billing

  • SaaS, Embed or Full Service

Our Turn-Key Solution Includes:

Additional Benefits

  • Increases Fee-For-Service Revenue Today

  • Readies Your Practice for Value Based Care

  • Puts YOUR Focus Back on Providing Care

  • No Need to hire additional Staff

The Future of Medicare Payments

You Can't Do CCM With Your EHR/EMR

By using predictive analytics, patients with "low", "medium", "high", and "rising" clinical and financial risks are indentified. By combining risk scores with other medical and scientific data, our Care Coaches will trigger personalized preventative plan services and other necessary treatments and/or testing procedures in a systematic way to support regular Doctor office visits. By managing each patients personalized care plan and prioritizing interventions -- all within a single workspace -- Providers gain a 360 degree view of each patient, guiding better decisions at the point of care.

Financial Forecast

Making important business decisions demands accurate intelligence. Get your comprehensive financial analysis - based on your service area - and get the knowledge you need to forecast your population effectively. 

Profit estimates of $400,000 annually per 1,000 patients for Physicians and $800,000 annually per 1,000 patients for Hospitals.

Practice Requirements

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  • Your practice must have an EMR/EHR system.

Active Patients

  • ​Patients mus have Medicare Part B or Medicare Advantage and been seen within the last 12 months.

  • Cannot be participating in another Care Management Program.-

We will Run Eligibility at No Cost to the Clinic Prior to Contracting

What We Need:



  • Signed BAA between your practice and our company


NPI #'s

  • Provide all NPI numbers for all Providers


CSV File

  • Provide all CSV file with Patient Demographics: including DOB, Gender, EMR/HER #, First / Last Name, Medicare ID.

W/in 3 business days we can provide your Next Revenue

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Care Management Training Center and SaaS



VIEW the leading CCM technology...
Schedule Your Online Demo >>
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Intelligent Technology

For the first time, DATA IS AGGREGATED FROM ACROSS THE CONTINUUM OF PROVIDERS AND SOURCES, IN REAL TIME. Providers gain actionable insights within clinical work flows to increase productivity and improve patient outcomes.

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Interoperable Data

Semantic interoperability—or the ability of two systems to exchange data in a meaningful way—remains a barrier to accurate data analytics and reporting. Effective data normalization and terminology management is critical to accurately capturing data -- which must become a priority to maximize reimbursement within MACRA’s Quality Payment Program (QPP) under the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). 


To coordinate care, health systems need to aggregate potentially "disparate data" from multiple sources and share that patient data to providers as needed. Our technology enables care teams to provide coordinated care while working at "top of license".

Our Care Management Platform:

  • Securely integrates with virtually any Medicare certified EHR -- from large scale health systems to independent practice models;​

  • Continuosly stratifies patient data and sort patients into high-, medium-, low- and rising-risk categories to assess: risks, hospitalization likelihood, non-adherence, motivation, and likelihood to experience higher risk;

  • ​Provides daily summary indicators and caseload, including tasks due for that day as well as a preview of upcoming work and any overdue items;

  • Recommends mitigations, facilitate medication review, and help our clinicians plan their day and prioritize tasks;

  • ​Employs evidence-based assessments that auto-generate patient care plans;

  • ​Shares patient information and care plans at the point of care -- across multiple EMRs -- delivering necessary data to all providers;

  • ​Ensures patient privacy by safeguarding access to patient health information;

  • ​Provides a 360 degree view of each patient, including lab results, medication history and documents;

  • ​Uses certified EHR to transfer patient data -- including billing data -- to your EHR and populate patient profiles with records from your practice.



*NO interruption of workflow, NO extra staff needed, and our service covers everything from integration to billing.

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Technology Highlights

  • OIG compliant 24/7 data capturing and billing;

  • secure & compliant EHR platform

  • data analytics and resource use;

  • patient portal with electronic medical record;

  • care coordination among all providers;

  • health information exchange among all stakeholders;

  • auto-generate patient care plans;

  • patient engagement and education;

  • medication therapy;

  • transitional care;

  • recommends mitigations and preventative plan services;

  • "top of license" reimbursement;
    And more...


Continually identify, assess, and stratify patient data to improve outcomes and decrease overall cost. 


As there are not enough providers to manage every patient continuously, this focus requires automation to support those providers and to carry out the large number of routine tasks that do not have to be performed manually.

Discover the only technology platform that delivers healthIT and interoperability in a way previously considered impossible.

Schedule Your Online Demo >>
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Provider-Patient Interaction

Providers average of 7-10 minutes in the exam room with each patient, and even then, the electronic health record (EHR) receives some of the attention.

When patients have multiple chronic diseases, it's improbable - within 7-10 minutes - to adequately educate them on their chronic conditions, medication adherence, plan of care, care coordination among all providers, and help them create goals.

The Risks of Low Engagement

Lower patient engagement is linked to higher rates of ER visits and re-hospitalization as well as less compliant with medications and treatment plans. While 28% of low-activated patients will be readmitted within 30 days of discharge, that number is significantly less at 12.8% for patients who are more involved in their treatment plan.


will be readmitted to the hospital within 30 days of discharge.


will experience a medical error due to miscommunications.


have poor care coordination between providers.


experience health consequences as a result of poor communication.


lose confidence in the healthcare system.

Source: Adapted from AARP & You, “Beyond 50.09” Patient Survey.

Care Management Highlights


Implement provider-guided, patient-centered care plan using clinical, behavorial, and educational measures.

Identify Barriers

By identifying barriers, we develop positive health outcomes by addressing healthcare behaviors in both patients and provider.

Care Coordination

Address communication barriers between care providers and patients utilizing specific behavioral, clinical, and educational principles to encourage change.

Medication Reconciliation

Medication reconciliation with review of adherence and any interactions; and oversight of patient self-management of medications.

24/7 Care

Anytime access will support patient’s full electronic record and documentation of their progress with our program.

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