From Intention to Completed Action
Every solution we offer is powered by our Motivational Patient Guidance framework — nine behavioral techniques that transform patient interactions from routine touch points into measurable next steps. Not engagement. Activation.
Explore Patient Activation →
Uncover What's Really in the Way
Our Activation Agents use the Stressor Inventory process to surface non-clinical blockers — transportation, finances, fear, confusion — and mobilize solutions before patients even ask. Removing barriers is where activation actually happens.
Explore Barrier Resolution →
The Right Nudge at the Right Moment
Our Enterprise GPS platform continuously monitors each patient journey, builds motivational profiles, and selects the next best action in real time — escalating to human Activation Agents when empathy matters more than efficiency.
Power of "Why" →
Intelligence Layered Into Every Interaction
AI doesn't replace our clinical and activation expertise — it amplifies it. From predictive risk scoring to real-time sentiment analysis and automated follow-up triggers, our AI layer ensures no patient slips through the cracks.
Explore Hospitals & Health Systems →
Explore Practices →
Explore FQHCs & Community Health →
Explore Payers & Health Plans →
The standard care management model follows a predictable pattern. Enroll the patient. Schedule a monthly call. Ask how they’re doing. Document the conversation. Bill the code. Repeat.
This model produces compliant records. It does not produce completed referrals, filled prescriptions, scheduled labs, or resolved barriers. The patient hangs up and navigates alone until the next call.
The economics look sound on paper. CPT 99490 reimburses $64.02 per patient per month for 20 minutes of chronic care management. At 250 patients, that’s $192,060 annually. But if those calls don’t change patient behavior, the downstream costs—avoidable ED visits, preventable readmissions, worsening chronic conditions—erase the reimbursement gains and then some.
Compliance without activation is an expensive phone call.
Behavioral science is clear on this point: information alone does not produce action. Telling a diabetic patient to schedule their A1C does not get the A1C scheduled. Asking a heart failure patient if they’re taking their medications does not resolve the cost barrier that’s causing them to skip doses.
Monthly check-ins fail because they address awareness, not barriers. The patient already knows they should follow up with their cardiologist. They don’t because they can’t get transportation, can’t afford the copay, can’t navigate the scheduling system, or can’t reconcile conflicting instructions from three different specialists.
These are activation symptoms—the non-clinical barriers that determine whether a patient follows through on their care plan. Standard care management programs don’t assess for them, don’t document them, and don’t resolve them. They ask ‘how are you doing?’ when they should be asking ‘what’s stopping you?’
Our care management model is built on the Motivational Patient Guidance (MPG) framework—nine behavioral science techniques that turn every patient interaction into a barrier resolution opportunity.
Instead of scripted monthly check-ins, our specialists identify the specific barriers preventing each patient from completing their next care step. Then they resolve those barriers during the call or immediately after it.
A patient who hasn’t filled a prescription gets the cost barrier identified and addressed—whether that means connecting them with a patient assistance program, coordinating with their prescriber for a generic alternative, or arranging pharmacy delivery. A patient who missed a follow-up gets the scheduling barrier resolved—transportation arranged, appointment confirmed, pre-visit instructions delivered.
Every touchpoint simultaneously captures billing documentation, closes quality gaps, and updates risk adjustment data. The clinical work and the administrative work happen in the same interaction. Nothing is left on the table.
The activation model becomes exponentially more powerful when it spans all five CMS care management programs. A patient who discharges from the hospital enters TCM. Our team reaches them within 48 hours, resolves medication confusion, confirms follow-up appointments, and addresses discharge barriers.
When the 30-day TCM window closes, they transition seamlessly to CCM. Their RPM data informs every CCM call—when readings spike, our team contacts the patient before it becomes an ED visit. Their annual wellness visit captures updated ICD-10 codes that strengthen risk adjustment scores.
One patient. One relationship. Five revenue streams. Every touchpoint building on the last.
This is what separates a care management operation optimized for compliance from one optimized for activation. The billing codes are the same. The documentation is the same. The outcomes are not.
When care management is built for activation, the financial model compounds. Reimbursement capture improves because patients stay enrolled—they see value in the relationship, not just a monthly phone call they tolerate. Quality measures close because barriers get resolved, not just identified. Risk adjustment scores improve because every interaction documents complete clinical data.
And the downstream savings multiply: fewer avoidable ED visits, fewer preventable readmissions, fewer patients lost to follow-up. The care management program stops being a cost center that generates modest reimbursement and becomes the infrastructure that holds your entire value-based care strategy together.
HIPAA Compliant · SOC 2 Certified · NIST Compliant
SEE IT IN CONTEXT
This page explains the behavioral science that differentiates our care management model. For the full operational picture—including how we deliver all five CMS programs through a single team—visit the main Care Management page.
Schedule a consultation and see how we eliminate abandoned calls and protect the revenue your phones are losing today.