Principal Care Management for High Complexity Single Condition Patients
Not every patient needs full CCM. Some need focused, sustained care management for one high complexity chronic condition. We deliver PCM as an extension of your team, using the same activation methodology that drives outcomes across all our care management programs.
Patients with a single high complexity chronic condition often fall into a gap. They don’t qualify for or need the breadth of full CCM. But they still need consistent outreach, care coordination, and follow through support to manage their condition and avoid deterioration.
Without a dedicated PCM program, these patients get the same reactive care model as everyone else: annual visits, occasional follow ups, and self managed care plans. For conditions like advanced COPD, complex diabetes, or treatment resistant hypertension, that’s not enough. These patients need proactive monthly contact, and your staff doesn’t have the bandwidth to provide it alongside everything else.
Root Cause
The Real Cost Isn’t Missed Reimbursement. It’s the Clinical Outcomes Gap.
Patients with a single high acuity condition who don’t receive consistent care management are among the most likely to experience avoidable acute events. A COPD patient whose exacerbation symptoms go unmonitored ends up in the ED. A diabetic patient whose medication regimen isn’t being actively managed develops complications that could have been prevented with monthly follow up.
These are the patients where focused activation has the highest return per dollar invested. One condition. One care plan. Consistent monthly outreach that ensures they’re following through on every step.
Our Approach
Our Approach
We operate as an extension of your care team with licensed RN triage, activation-trained agents, and closed-loop barrier resolution that converts every patient interaction into a completed, in-network next step.
Focused on one condition, structured for activation
PCM outreach is targeted to the specific chronic condition requiring management. Every call is built around that condition’s care plan, barriers, and follow through requirements.
Complements your broader care management strategy
PCM slots into your existing care management infrastructure alongside CCM, TCM, AWV, and RPM. Same team. Same quality standards. Same compliance posture.