Chronic Care Management
Bringing hospital-level care into the patient's home.
A virtual-first, AI-driven digital health platform that connects patients, hospitals, EMS, a dedicated virtual care team (RN, LCSW, MA, CHW, APP) and community services — extending equitable access to care while strengthening EMS as the bridge between hospital and community.
Background & Problem
131 million US citizens live with multiple chronic conditions (MCC) and average 2 preventable major chronic health events per year. Care today is siloed: less than 10% of MCC patients receive even basic care management. RPM data is noisy, CCM is administratively burdensome, and most patients have dozens of predictable health variables — physical, social, mental, behavioural — that need coordinated monitoring, not a single biomarker.
Solution & Approach
Through a collaborative effort between local EMS, hospitals, primary care and community health centres, we operate a Care-as-a-Service model on top of an enterprise AI platform. Closed-loop daily monitoring through IoT RPM and static devices/app feeds the Digital Dynamic Medical Record. The system automatically tracks care minutes for reimbursement and value-based metrics, so care teams get paid on time with less stress and better outcomes.
Core Architecture
Care Manager RN with full care team (LCSW, MA, CHW, APP, Community EMS) overseeing each case 24/7
Closed-loop daily monitoring via IoT RPM and static devices
Collaborative care documentation with MCC reimbursement-ready audit trail
Patient-, caregiver- and physician-friendly dashboards with actionable, linked alerts
Automatic time-tracking for value-based reimbursement
API integration with EMRs, AI models, point-of-care diagnostics and other software stacks
Tangible Benefits
Reduce major chronic health events (MCHE) and 7/30/90-day readmissions
Lower total cost of care for payors and providers
Unlock CMS care-management CPT reimbursement (~$350 per patient per month)
Improve patient and provider satisfaction; reduce burnout
Equitable access to care in healthcare deserts and rural areas
Impact across the ecosystem
Patient
Hospital-level care at home, single point of access for records, family can co-manage care remotely.
Payor
Reduced overall cost of care, fewer preventable events, better fraud and billing oversight.
EMS
New high-impact reimbursement from previously unused capacity — double or more net income.
Hospital
Up to $4,200 PPY plus bonuses, fewer readmissions, improved ED throughput, higher patient retention.