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The Problem: Managing Chronic Disease In U.S.

Geographic distribution of chronic disease prevalence scores by quartile across Zip Code Tabulation Areas (ZCTAs). Chronic disease prevalence scores ranged from 0 to 20 with a score of 0 meaning the ZCTA was in the 25th percentile and a score of 20 meaning the ZCTA was in the 75th percentile of prevalence for each chronic disease examined

Chronic Disease Prevalence in the US: Sociodemographic and Geographic Variations by Zip Code Tabulation Area. https://lnkd.in/eF7DKA5y

90% of U.S. adults aged 65 and older have at least one chronic condition.

75% of U.S. adults ages 35–64 have at least one condition.

60% of U.S. adults aged 18–34 have at least one condition.

42% of U.S. Adults have 2 or more, and 12% have at least 5 chronic conditions!

These include diabetes, cardiometabolic syndrome, heart disease, high blood pressure, cancer, depression, dementia, obesity, substance abuse, glaucoma, diabetic retinopathy, and more.

The Solution: Expanding Access To Care At Home

Augmenting in-office visits with at-home Telehealth Solutions
provide patients with access to the resources they need
to effectively manage their chronic conditions.

TELEHEALTH SOLUTIONS

Improve Patient Outcomes

Reduce Staff Workload

Generate New Revenue

Telehealth For Patients At Home

Remote Therapeutic Monitoring Solutions
Healthcare Monitoring Devices in Georgia

Our Telehealth Professionals monitor patient’s physiological and non-physiological data daily!

Patients, family, and caregivers can text, call, and email their Telehealth Professional.

High-touch communication is how we take patient adherence to a new level!

Patients with chronic ophthalmology conditions are eligible for Remote Telehealth Services.

These include Chronic Care Management (CCM), Remote Physiological Monitoring (RPM),

Principal Care Management (PCM), and Remote Therapeutic Monitoring (RTM).

Telehealth Clinical Solutions

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Chronic Care Management (CCM) / Principal Care Management (PCM)

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Remote Therapeutic Monitoring (RTM)

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Remote Patient Monitoring (RPM)

Chronic Care Management (CCM)

Chronic Care Management (CCM) brings structure to patient care delivered remotely – between office visits. Designed for patients “with two or more chronic conditions expected to last at least 12 months or until the patient’s death, and place the patient at significant risk of death, acute exacerbation, or functional decline.” Medicare introduced CCM more than ten years ago to incentivize healthcare providers to maintain monthly contact with patients by phone, email, and text. This high-touch, remote care model has proven effective at early detection, early intervention, reduced visits to the ER, reduced hospital admissions, and generally improved patient outcomes.

The monitoring device of choice for CCM is the Physician’s Care Plan! The CMA uses this to guide patient engagement during monthly patient check-in calls.

Remote Therapeutic Monitoring (RTM)

RTM relies on mobile apps to remotely monitor and manage patients from the comfort of their home. Remote care teams communicate with patients daily to assess non-physiological patient-reported data.

These include medication adherence, response to therapy, pain/mood/symptom tracking, and more.
These data provide critical insights into which therapies and medications are working or not working.
By informing care decisions in real time, physician-led care teams intervene early to improve

Remote Physiological Monitoring (RPM)

Remote Patient Monitoring (RPM) simply monitors patients remotely! RPM requires an FDA-cleared device capable of collecting physiological data (BP, BG, SpO,, weight, and temperature) in one location (at home, for example) and electronically transmitting those data to the CMA and/or the MD at a different location (the CMA’s home, or the MD’s office, for example. The CMA monitors the incoming readings daily, calls the patient by phone monthly, and family, communicates with patients, family, caregivers, and physician-led care teams throughout the month.

Prinicpal Care Management (PCM)

Principal Care Management (PCM) is a set of non face‑to‑face care management services for patients who have a single serious or high‑risk chronic condition that is expected to last at least 3 months and requires focused, ongoing management and coordination by one clinician. PCM is similar to CCM but is centered on one primary condition vs 2+ conditions.

Medicare Coverage Enables Patient Enrollment

Medicare, Medicare Advantage, and Most Private Payors cover the cost of CCM, RPM, PCM, and RTM.

87% of Medicare recipients have some form of supplemental coverage i.e., Medigap, Medicaid, Employer.

Almost 9 out of 10 Medicare patients can enroll in Telehealth Services without the burden of a co-pay

Enrollment Drives Care Plan Adherence

The State of RPM for Chronic Disease Management in the U.S.

J Med Internet Res 2025;27:e70422 URL: https://www.jmir.org/2025/1/e70422
DOI: 10.2196/70422
Mayo Clinic

RPM, CCM, RTM, and PCM are pivotal tools that helps bridge the home-office divide.
Individual health data are collected outside the office setting and transmitted to care teams. Informed, Physician-led care planning facilitates more optimal disease management.

Care Plan Adherence Improves Patient Outcomes

Adherence to prescribed medications is associated with improved clinical outcomes for chronic disease management and reduced mortality from chronic conditions. Conversely, non-adherence is associated with higher rates of hospital admissions, suboptimal health outcomes, increased morbidity and mortality, and increased health care costs. http://dx.doi.org/10.15585/mmwr.mm6645a2

Professionally Staffed Remote Care Teams

Physician-led Remote Care Teams monitor patient’s

Physiological and Non-Physiological health – daily

Outsourcing Reduces Staff Workload

Medical Group Practices can augment in-office care with our Remote Telehealth Care Teams.


Our remote clinical and administrative resources enable more time for in-office patient care.

This reduced in-office workload results in higher employee satisfaction and retention.

Telehealth Customer Segments

PRIMARY CARE

INTERNAL MEDICINE

CARDIOLOGY

RESPIRATORY & PULMONOLOGY

ENDOCRINOLOGY

NEPHROLOGY

OPHTHALMOLOGY

NEUROLOGY

ONCOLOGY

MENTAL/BEHAVIORAL HEALTH

GASTROENTEROLOGY

OB/GYN

ORTHOPEDICS

PHYSICAL THERAPY CENTERS

PAIN CLINICS

CHRIROPRACTIC MEDICINE

WEIGHT LOSS SPECIALISTS

SKILLED NURSING FACILITIES

ASSISTED LIVING FACILITIES
PODIATRY