Services

A complete virtual nursing layer for modern practices.

From CCM and RPM to transitional care and patient outreach — every program is RN-led, billing-aware, and designed to scale.

CPT 99490 · 99439 · 99487 · 99489

Chronic Care Management (CCM)

Monthly non-face-to-face care coordination for Medicare patients with two or more chronic conditions.

For the Practice
  • ·Recurring monthly Medicare revenue
  • ·Improved HEDIS metrics
  • ·No added staffing burden
For Patients
  • ·Dedicated RN care coordinator
  • ·Medication and care plan reviews
  • ·24/7 access to clinical staff
CPT 99453 · 99454 · 99457 · 99458

Remote Patient Monitoring (RPM)

Daily physiologic data collection from connected devices with RN review and intervention.

For the Practice
  • ·Predictable RPM revenue stream
  • ·Early detection of deterioration
  • ·Reduced readmissions
For Patients
  • ·Blood pressure, glucose, SpO₂ tracking
  • ·Personalized clinical follow-up
  • ·Better disease control
Bundled within CCM/RPM time

Care Coordination

Cross-provider coordination across specialists, pharmacies, and community resources.

For the Practice
  • ·Closed referral loops
  • ·Stronger network integrity
  • ·Better continuity of care
For Patients
  • ·Easier navigation of the system
  • ·Faster specialist access
  • ·Reduced care gaps
CPT 99495 · 99496

Transitional Care Management

Post-discharge outreach within 48 hours and structured 30-day TCM follow-up.

For the Practice
  • ·TCM reimbursement
  • ·Reduced 30-day readmissions
  • ·Cleaner discharges
For Patients
  • ·Safer transitions home
  • ·Medication reconciliation
  • ·Clear next-step guidance
Counted toward CCM time

Medication Adherence Follow-Up

Structured outreach to verify adherence, identify barriers, and coordinate refills.

For the Practice
  • ·Higher Star Ratings
  • ·Lower acute event risk
  • ·Improved patient satisfaction
For Patients
  • ·Fewer missed doses
  • ·Cost and side-effect support
  • ·Coordinated refills
Quality / VBC programs

Care Gap Tracking

Identification and closure of preventive and chronic care gaps across the panel.

For the Practice
  • ·Improved quality bonuses
  • ·MIPS / value-based wins
  • ·Clean dashboards
For Patients
  • ·Timely screenings
  • ·Preventive interventions
  • ·Whole-person care
AWV CPT G0438 · G0439

Patient Outreach Programs

Concierge-style outreach campaigns for AWVs, vaccinations, and panel re-engagement.

For the Practice
  • ·Higher visit volume
  • ·Stronger panel loyalty
  • ·More billable encounters
For Patients
  • ·Personal reminders
  • ·Easy scheduling
  • ·Feeling cared for