Healthcare organizations are increasingly adopting remote patient monitoring (RPM) and chronic care management (CCM) to help more efficiently manage care for patients with chronic conditions. These remote care programs enable providers to extend their reach beyond traditional healthcare settings by leveraging remote capabilities, deeper clinical insights, and enhanced care coordination.

For healthcare systems, implementing RPM and CCM can help enhance post-acute care and reduce unnecessary hospital readmissions, freeing up medical staff to care for their most critical patients. For medical practices, these programs aid providers in more effectively managing patients’ chronic conditions, fostering adherence to treatment plans, streamlining operations, and offering expanded opportunities for reimbursement. Similarly, for health plans, RPM and CCM serve as tools to advance population health, mitigate risks, and reduce unnecessary healthcare utilization and costs.

Questions to Ask a Remote Care Partner

For healthcare entities, the key to ensuring a successful remote care program is preparation, planning and partnering with the right provider. The following are several of the most frequently asked questions and answers regarding remote patient monitoring and chronic care management:

1. What are CCM and RPM?

Chronic Care Management:

CCM is a primary care service where individuals with two or more chronic conditions can receive coordinated care services to help manage their health. These services include a comprehensive care plan, regular check-ins, education and goal setting. The goal of these services is to help patients understand their health conditions and provide the opportunity for more timely adjustments in treatment.

Typically, these services are provided remotely and allow providers to bill 20 minutes or more of care coordination services per month. With CCM, there are no device requirements, and the service can be billed in conjunction with RPM, although time requirements must be met separately.

Remote Patient Monitoring:

In contrast, RPM allows providers to remotely monitor and manage their patient’s chronic conditions utilizing digital devices that test blood pressure, blood sugar, and oxygen levels, and measure weight. The devices send the results to the provider, who is alerted if a reading falls outside of the desired parameters and can then intervene accordingly.

With RPM, the service must be deemed medically necessary and ordered by a qualified healthcare provider who can bill for E/M services. RPM also involves using FDA-defined devices with at least 16 days of readings per 30 days and requires at least 20 minutes per month by clinical staff.

2. What are the key differences between RPM and CCM?

Both CCM and RPM play pivotal roles in facilitating patient care outside traditional office visits. However, they differ in their approaches. CCM includes a comprehensive care plan, continuous patient support and educational resources. Conversely, RPM involves providing patients with devices to monitor their physiological data and delivering real-time results directly to healthcare providers.

CCM is most beneficial for patients with two or more chronic conditions, offering personalized support such as annual wellness visits, transitional care, primary care management, and cognitive testing. On the other hand, RPM is best for individuals managing one or more chronic conditions within a treatment regimen, empowering them to proactively manage their health between office visits.

3. How can CCM and RPM be used together to benefit patients with chronic conditions?

Although these services have different functions, they complement each other well and can be combined to provide patients with comprehensive care that closes the gaps between in-person appointments. CCM provides information to patients between visits that help ensure the patient’s health and well-being, while RPM provides the physiologic data to physicians who need to monitor changes in health that may identify escalating conditions and require intervention.

RPM and CCM programs improve individual outcomes and make a positive impact on population health, thereby allowing healthcare organizations to optimize value-based care.

4. What are the key benefits of RPM and CCM services?

RPM and CCM provide many advantages, including enhanced access to care, early intervention opportunities, improved health outcomes and increased patient engagement. In addition, they allow at-risk patients to remain at home, limiting transportation challenges and the risk of exposure to infectious diseases.

5. What clinical evidence supports the use of RPM and CCM services?

According to the Centers for Medicare and Medicaid Services (CMS), CCM lowered hospital, emergency department and skilled nursing facility costs and reduced the likelihood of hospital admissions. In fact, the evidence has shown that CCM:

  • Decreased hospitalizations by almost 5%
  • Reduced emergency department (ED) visits by 2.3% and
  • Increased preventative care visits by 8%

Additionally, there is a wide range of evidence supporting the clinical benefits of remote patient monitoring. For example, a KLAS research report found that RPM was associated with a:

  • 38% reduction in hospitalizations
  • 25% reduction in ED visits
  • 25% reduction in readmissions
  • 25% increase in patient satisfaction
  • 17% reduction in costs

6. Who can provide RPM or CCM services?

RPM and CCM can be ordered and provided by physicians and other qualified healthcare professionals. Clinical staff can deliver and manage RPM or CCM under the general supervision of the billing provider.  

To receive RPM services, patients must have at least one chronic condition or an acute illness/condition. For CCM, a patient must have multiple (two or more) chronic conditions expected to last at least 12 months, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.

8. Can RPM and CCM be billed together?

Yes. CMS recognizes that these services complement one another and allows both RPM and CCM to be billed together. However, the individual time requirements for each service must be met separately. Billing together requires a provider to deliver at least 40 minutes of services: 20 minutes of RPM and 20 minutes of CCM.

Finding the Right Remote Care Partner

When it comes to implementing a remote care program such as CCM or RPM, finding the right partner can make all the difference in the success of the program. Connect America’s remote care services help you support, monitor, and manage care for your patients with chronic conditions without over­burdening your staff.

Our program support is flexible to meet your organization’s needs and includes:

  • A dedicated team of qualified, licensed clinicians assigned to your practice
  • Customized workflows
  • Filtering to bring emergencies to your attention
  • Operating under your supervision, without burdening your staff

A Complete End-to-End Solution

With our complete end-to-end solution, we make it easy for you to quickly get your program up and running and keep it on track, by including:

  • Full-service clinical monitoring and billing
  • Facilitation of patient outreach, education, and enrollment on behalf of the practice
  • Communication and reminders to ensure patient adherence
  • Devices shipped directly to your patients with no setup required
  • White-glove service and support for practices and patients

The result is simple: more patients enrolled, increased patient adherence, improved health outcomes and maximum reimbursement.