Provide focused, high‑value care for patients with a single serious chronic condition
Principal Care Management (PCM) programs support patients with one serious chronic condition—such as congestive heart failure, COPD or cancer—requiring intensive management. Providers benefit from more targeted care, while patients receive highly personalized support. PCM can enhance patient engagement, improve care coordination and help meet quality metrics.
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 (99424–99427) and maintain audit trails
Regular touchpoints empower patients to manage their condition and ask questions
PCM creates new reimbursement opportunities while supporting value‑based goals
Personalized plans help meet disease‑specific benchmarks (e.g., heart failure readmissions, COPD management).
Integration with CCM, RPM and TCM ensures continuity across the care continuum.
Our PCM program brings together pharmacists, nurses and coaches to focus on one dominant condition. We use predictive analytics to identify patients who qualify for PCM and tailor interventions accordingly. By embedding medication expertise and SDOH support, PharmD Live® improves outcomes while generating sustainable revenue for providers.