Care managers contact patients each month to assess symptoms, progress and barriers
Establish and monitor SMART goals tailored to the patient’s primary condition
Optimize therapy, manage side effects and deprescribe inappropriate medications.
Identify social determinants of health that affect the condition and connect patients to community resources
Data integration across EHRs, HIEs and remote devices enables holistic views of patient health
Streamlined workflows assign appropriate CPT codes and maintain audit trails
Regular touchpoints empower patients to manage their condition
Personalized plans help meet disease‑specific benchmarks (e.g., heart failure readmissions).
PCM creates new reimbursement opportunities while supporting value‑based goals
Integration with CCM, RPM and TCM ensures continuity across the care continuum.