Unmanaged diabetes, heart disease, and various other conditions often result in many expensive interventions, hospitalizations and poor outcomes.

CMS reimburses for Principal Care Management (PCM) services provided to beneficiaries with a single chronic condition needing to stabilize that condition following exacerbation or hospitalization.

The challenges of successful in-house Chronic Care Management (CCM) and Remote Patient Monitoring (RPM) programs

Remote patient monitoring (RPM) programs (a subcategory of homecare telehealth), retrieve patient health status and data readings from automated personal devices a patient has or wears at home (e.g.heart or glucose monitor).

The Annual Wellness Visit (AWV) is a Medicare specific annual health status check where patients have vitals and health status indicators assessed, to provide an opportunity for earlier support and intervention for chronic conditions or concerns.

Transitional Care Management is a program designed to support and track Medicare patients in the 30 days following discharge from a hospital or treatment facility.