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CARE MANAGEMENT

Five Reimbursable Programs. One Activation Infrastructure.

CMS reimburses five distinct care management models. Most organizations run them in silos or not at all. We deliver all five through a single team, a single EHR integration, and a single activation methodology. Your patients get connected care. You get connected revenue.
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The Challenge

Your Problem

Medicare’s care management programs were designed to keep patients healthier between visits, reduce avoidable utilization, and generate new revenue for the organizations delivering the care. The economics are clear. The execution is where it falls apart.

You can’t staff five programs with one team

CCM, RPM, PCM, AWV, and TCM each have their own billing codes, documentation requirements, eligibility criteria, and outreach cadences. Building internal capacity across all five means hiring, training, and retaining multiple specialized roles. Most organizations pick one program, run it partially, and leave the rest on the table.
Staffing and bandwidth

Siloed programs create siloed outcomes

When CCM and RPM don’t talk to each other, patients get duplicate calls, conflicting instructions, and fragmented care. When AWV and TCM operate independently, the data captured in one program never informs the other. Your patients experience the silos even if your org chart says they shouldn’t.
Connected care management

Revenue leaks at every seam

Every care management touchpoint is a billing opportunity, a risk adjustment documentation opportunity, and a quality gap closure opportunity. When programs run separately or don’t run at all, you miss billable minutes, leave RAF codes undocumented, and watch quality measures stay open.
Revenue capture math
Root Cause

As Healthcare Experts, We See the Deeper Problem

The real problem isn’t that care management is hard to execute. It’s that the model most organizations use was never designed to produce outcomes.
Compliance vs. Activation

Care management without activation is just documentation

Most programs follow the same pattern: call the patient, ask how they’re doing, document the conversation, bill the code. The call produces a compliant record. It doesn’t produce a completed referral, a filled prescription, or a scheduled lab. The patient hangs up and navigates alone.
Follow through failure
Duplicated Infrastructure

Five programs running independently cost more than five programs running together

Each program has its own enrollment workflow, documentation template, QA process, and reporting cadence. When they’re separate operations, you duplicate infrastructure, train multiple teams, and create gaps between handoffs.
Operational efficiency
Uncaptured Value

Your highest acuity patients carry the most uncaptured value

Patients with multiple chronic conditions, recent hospitalizations, and complex social needs are eligible for multiple care management programs simultaneously. They’re also the patients with the most open quality gaps, the most incomplete risk adjustment data, and the highest avoidable utilization risk.
Risk adjustment gaps
Our Approach

One team. One integration. Five activated programs.

We operate as a dedicated extension of your clinical team, delivering all five CMS reimbursable care management programs through a single operational infrastructure. Same specialists. Same EHR integration. Same activation methodology. No silos. No gaps between programs.

  • Activation psychology at every touchpoint

    Our specialists are trained in the Motivational Patient Guidance framework. Nine behavioral science techniques that turn care management calls into completed next steps. Not compliance. Activation.

  • Single EHR integration, five programs

    We document directly in your EHR across CCM, RPM, PCM, AWV, and TCM. One integration. One audit trail. Complete data flowing to every clinician who treats the patient.

  • White labeled under your brand

    Patients experience our team as your team. Consistent voice, your protocols, your escalation paths. No visible seams between programs or between our team and yours.

  • Connected patient journeys, not siloed programs

    A patient who discharges from the hospital starts TCM. When the 30 day window closes, they transition to CCM. Their remote monitoring data from RPM informs every CCM call. One relationship. Five revenue streams.

  • Full billing capture across all codes

    We manage eligibility, enrollment, outreach, documentation, and billing across every applicable CPT code. No billable minutes left uncaptured.

Check-ins aren’t enough

Five Reimbursable Programs

Connected care management across every stage of the patient journey

We deliver all five CMS reimbursable care management programs through a single team and a single EHR integration.
Connected Activation

The patient journey, not the billing code, drives the model

A patient with heart failure and diabetes is discharged from the hospital. Here’s how our connected infrastructure activates them across every stage.
1
Days 1 – 2

TCM Outreach

Confirms discharge instructions, medications, and follow up appointments. Resolves transportation and access barriers during the call.

2
Days 3–30

TCM + RPM

Ongoing TCM management. Remote monitoring tracks weight, blood pressure, and blood glucose daily. When readings spike, our team contacts the patient before it becomes an ED visit.

3
Day 31+

CCM + RPM

TCM transitions to CCM. Monthly activation calls continue. RPM data informs every conversation. Barriers are resolved. Next steps are completed.

4
Annual

AWV

The annual wellness visit captures updated ICD-10 codes, strengthening risk adjustment scores and closing quality gaps.

One patient. One relationship. One team. Three active programs generating revenue, closing quality gaps, and preventing avoidable utilization simultaneously.

PROVEN AT SCALE

Results across every care management program we deliver

A large healthcare organization replaced internal triage with Guideway Care. The result: consistent quality, predictable costs, and nearly $1M in projected savings.
$192,060
Projected annual CCM reimbursement (250 patients)
99.4%
Quality KPI pass rate
35%
Fewer readmissions
~100%
Appointment adherence
31%
Higher patient satisfaction
24/7
Coverage, zero gaps
HIPAA Compliant  |  SOC 2 Certified  |  NIST Compliant

Ready to capture revenue across every care management program?

Schedule a consultation and see how a single activation infrastructure can deliver CCM, RPM, PCM, AWV, and TCM without adding headcount or complexity.

Schedule a Consultation