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Human-led care, AI-enhanced performance

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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HIPAA Compliant  |  SOC 2 Certified  |  NIST Compliant

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.

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.

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.
Root Cause

As Healthcare Experts, We See the Deeper Problem

Most care management 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, not a completed referral, a filled prescription, or a scheduled lab. The patient hangs up and navigates alone. Multiply that across five programs, each with its own enrollment workflow, documentation template, QA process, and reporting cadence, and you’re paying for duplicated infrastructure that produces duplicated inaction. The patients caught in the middle are your highest acuity, highest cost, highest risk patients. They’re eligible for multiple programs simultaneously, carrying the most open quality gaps, the most incomplete risk adjustment data, and the highest avoidable utilization risk. The programs exist. The documentation exists. The activation doesn’t.
Our Approach

One team. One integration. Five possible 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 possible 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.
PROVEN AT SCALE

From operational strain to SLA-exceeding performance

A large healthcare organization replaced internal triage with Guideway Care. The result: consistent quality, predictable costs, and nearly $1M in projected savings.
99.4%
Quality KPI pass rate
4×
Staff scale-up since inception
~$1M
Projected 3-year savings
24/7
RN coverage, zero gaps

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