Virtual Care · Chronic Care Management
Chronic care that continues between visits.
A dedicated RN team coordinates care for your patients with chronic conditions between office visits — a reimbursable service line you offer without adding staff.
At a glance
- Who runs it
- A dedicated RN care team
- What it covers
- Care plans, monthly coordination, adherence
- Your role
- Escalation and clinical oversight
- Revenue
- Recurring, reimbursable CCM services
- Staffing
- No additional hires
The challenge
Chronic conditions don't wait for the next appointment.
Patients managing chronic conditions need steady coordination between visits — medication adjustments, questions, adherence, the small course-corrections that keep them stable. Miss those, and problems compound quietly until the next appointment.
Chronic care management is a proven, reimbursable answer. The reason most practices don't offer it is simply capacity: there's no one on staff with the time to run it well.
The model
An RN team that manages the care between your visits.
Our nurses build from each patient's care plan, coordinate the between-visit work, and keep the documentation reimbursement-ready — escalating to your physicians whenever clinical judgment is needed. It functions as an extension of your team, not a handoff of it.
CCM and RPM work best together. Chronic care management coordinates the care; remote patient monitoring watches the vitals. Many practices run both from the same RN team.
Explore RPMWhat's included
Coordination, handled end to end.
Six parts of a chronic care management engagement, run by the RN team on your behalf.
- A comprehensive care plan
- Each eligible patient gets a documented, personalized care plan the team works from — and keeps current.
- Monthly care coordination
- Regular non-visit check-ins keep patients on plan and surface issues before the next appointment.
- Medication & adherence support
- Ongoing help with medication and care-plan adherence, where the largest gaps in chronic care open up.
- Coordination across providers
- The team helps connect the dots between specialists, so care doesn't fall through the cracks between them.
- Escalation to your physicians
- Anything that needs clinical judgment routes straight back to your team — you stay in control of care.
- Reimbursement-ready documentation
- The coordination work is captured to support your chronic care management claims.
For your patients
- Steady support and coordination between appointments
- Better medication and care-plan adherence
- Fewer things falling through the cracks across providers
For your practice
- An RN-led extension of your clinical team — no new hires
- A reimbursable, recurring chronic care management line
- Improved compliance and engagement between visits
- Documentation kept ready to support your claims
Add chronic care management without the overhead.
A short call — no obligation. We'll walk through eligibility, the workflow, and the revenue side.