A scalable, profitable remote care service line for Associated Physicians Group: remote monitoring and chronic care management for the Medicare patients in APG’s primary care, built into eClinicalWorks as the practice moves onto it, billed under APG’s own NPIs, and run by your team, ours, or both
Medicare is changing what it pays primary care for. Four shifts are under way at once, and each one lands in the same place: the weeks between a patient’s visits. For a practice whose Medicare patients carry hypertension, diabetes and kidney disease together, those weeks decide how the year goes.
Associated Physicians Group is an independent Metro East practice, not owned by a hospital system, that brings interventional pain care, physical therapy and primary care under one roof in O’Fallon, Alton, Edwardsville and Swansea. Its insurance-based primary care line is small and old in the way that makes remote care pay: the traditional-Medicare patients of its four primary care clinicians average 74 years old, about three in four have hypertension and one in three has diabetes. APG is moving the practice onto eClinicalWorks, which sets the moment to decide how care between visits runs from here.
A Medicare panel averaging 74 years old, in which hypertension and high cholesterol are the norm and diabetes, kidney disease and heart disease are common.
74% of APG’s primary care traditional-Medicare patients carry a hypertension diagnosis. Home readings catch what one office reading misses and let the care team adjust medication month to month instead of at the next visit.
34% of these patients have diabetes and 32% chronic kidney disease, usually alongside hypertension. Two or more chronic conditions is the patient chronic care management was written for.
33% have ischemic heart disease, 20% atrial fibrillation, 17% heart failure and 17% COPD. APG’s primary care clinicians manage them in the office; daily weight, blood pressure and oxygen saturation fill in the months between.
Each step below added offices, clinicians or capability. Click through the steps. The next step adds the part none of them covers: daily readings and a care team between visits.
Each part of APG touches a patient at one moment: a primary care visit, a wellness visit, a diabetes class, a pain procedure, a therapy session, a hospital discharge. A remote care service line connects them, so a patient who leaves one visit is still being watched until the next one. Select any part of the practice to see what changes.
APG’s clinicians set the protocols and own every clinical decision. Who does the monthly work is APG’s choice: CoachCare’s care team, APG’s own staff on CoachCare’s platform, or a split of the two (chapter 04 compares them). Either way the program runs through the eClinicalWorks system APG is moving onto, from the first flag on a patient’s chart to the claim at month end.
The program starts with the panel, not a referral pad. eClinicalWorks holds the diagnoses, vitals, labs and medications. Patients with uncontrolled hypertension, diabetes, kidney disease or several chronic conditions are flagged using criteria APG’s clinicians set, so the right patients surface at a chronic-care visit, at an annual wellness visit, or on an outreach list.
Example criteria. APG’s clinicians set and own the flag logic for each condition.
Patients enter at an office visit, at a chronic-care or annual wellness visit, or after a hospital stay. Either way they land in the same monthly loop: office visits, care management and physiologic monitoring, each one informing the next.
BP 162/96 on three agents and an A1c above 9. The clinician places the remote care order during the chronic-care visit, or at the annual wellness visit.
Cellular cuff and glucometer at home, a welcome call by phone, and how to take a reading that counts.
99453Home averages drive medication changes month to month; the CCM call covers the other conditions.
99454 · 99457 · 99490Office visits ↻ care management ↻ physiologic monitoring.
Flagged in eClinicalWorks when the discharge notice arrives. Devices ordered to the home.
Contact within two business days, medication reconciliation, an office visit in 7–14 days.
TCM 99495 · 99496Readings start right away. The short-month device code covers the first partial month.
99453 · 99445 · 99490Office visits ↻ care management ↻ physiologic monitoring.
The clinician orders from the chart, or a CoachCare enrollment specialist working in the office enrolls the patient during the visit.
Cellular devices arrive ready to use. No Wi-Fi, no smartphone and no home internet needed, and nothing for the patient to pair.
The patient’s assigned care manager walks through the device, the routine, and who to call. The routine is set to fit the patient’s day.
Readings reviewed, outreach logged, care plan updated, escalations routed. Repeats every month.
From the enrollment flag in eClinicalWorks to the first billable day of service. Enrollment status is visible in the chart the whole way through, at every office.
Readings that settle are logged in the chart and visible to the clinician without paging anyone.
Out-of-range readings get a retake and symptom check first. A confirmed trend goes to the clinician or nurse each office designates, in eClinicalWorks, with the readings and a recommended next step attached.
Chest pain, new shortness of breath or stroke signs reported on a call: the care team calls 911 with the patient on the line, then notifies the office. A critical reading on its own goes to the office. This cannot be configured away.
At month end, three things come out of the program: clean claims in eClinicalWorks, an operational report for the practice’s leadership, and a clinical outcomes report for the clinicians.
CoachCare is the only care-management application integrated with eClinicalWorks that creates claims automatically. No one builds a claim by hand, patient by patient, month by month.
A monthly scorecard for the practice. Sample below at the modeled month-12 census.
A 24-month forecast for an APG remote care service line: remote monitoring and chronic care management across the primary care Medicare panel in scope, priced at the East St. Louis locality’s CY2026 Medicare rates with every patient priced at the Medicare amount, alongside what the program does for patients and for the people who run it.
Two chronic-care visits a year leave 363 days with no data. RPM bills only when a patient takes readings on at least 16 days in a month, so an enrolled patient gives the care team at least 192 days of readings a year.
Hypertension is the most common condition on APG’s primary care panel and the one home monitoring moves fastest. Home averages give the care team a monthly reason to adjust medication, and the documented result is the home number, not one rushed office reading.
Cardiac Solutions, a physician-owned cardiology practice with three West Phoenix offices, put 2,738 patients on CoachCare RPM with home blood-pressure monitoring.
APG’s primary care is scored on a fixed set of quality measures, through MIPS and the Medicare Shared Savings Program measure set. Most of them depend on work this program does every month. Select a measure to see how.
Monitoring the panel every day tells the practice who needs to be seen now, not only who is next on the schedule. Patients surface from their home data, not only when they come in sicker.
APG’s primary care already bills transitional care after some hospital stays. The next 30 days decide whether a patient comes back, and remote monitoring and chronic care management carry the patient past them.
Flagged in eClinicalWorks for post-discharge monitoring.
A call within two business days and medication reconciliation.
Readings start right away. 99445 bills the short first month.
Monthly RPM with CCM while it adds value.
Daily weight and BP from day two, three touches inside two weeks, a cardiology referral when the trend returns.
Oxygen saturation and symptoms after an exacerbation, with a quick visit to the patient’s own APG clinician before a return trip to the emergency department.
Glucose and BP while medications change after a stay, and a fluid check for patients with CKD.
Patients who carry hypertension or diabetes into recovery stay on their readings until the follow-up visit.
Every code the service line can bill, at CY2026 Medicare rates for the East St. Louis locality. Build a patient-month to see what one patient is worth.
CY2026 Medicare Physician Fee Schedule, non-facility, Illinois locality 12, East St. Louis (MAC 06102). Only one device code (99454 or 99445), one first-tier management code (99457 or 99470) and one care-management program (CCM or APCM) bill for a patient in a given month. About 56% of Medicare beneficiaries in Madison and St. Clair counties are in Medicare Advantage, so more than half of this panel is likely paid under Medicare Advantage contracts. Those plans must pay at no less than the Medicare rate, a floor; individual contracts set their own terms for the care-management code families, and the forecast prices every patient at the Medicare amount.
APG can hand CoachCare remote monitoring and keep chronic care management with its own team, or run both programs through CoachCare. Either way the program is net-positive. Select a deployment to redraw the charts.
| Full service line | Year 1 | Year 2 | 24 months |
|---|---|---|---|
| Unique patients, end of period | 324 | 324 | 324 |
| Contribution margin | $115,322 | $259,801 | $375,123 |
| Contribution margin runs −$6,202 in month 1 while the program ramps; positive from month 2. No shared-savings dollars are in these figures. | |||
APG already runs a between-visit program with its own staff. The move to eClinicalWorks is the natural point to decide who does that work from here. Full Service is the forecast on this page: devices, software and the CoachCare care team. Self Service gives APG the same devices, software and eClinicalWorks integration, and leaves enrollment, monitoring and the monthly minutes to APG’s own staff.
Self Service runs the same enrollment engine on the same panel and rates, with two things an in-house team usually carries: enrollment at three-quarters of the pace, because nobody’s whole job is enrolling, and a quarter fewer billable minutes, because time-based codes pay only when the minutes are logged every month. The comparison counts APG’s clinical minutes, a program lead and an enrollment role as cost, whether those people are already on payroll or not.
| 24 months | Full Service | Self Service |
|---|---|---|
| Contribution margin to APG | $375,123 | −$31,663 |
| Contribution margin, Year 1 | $115,322 | −$86,982 |
| Contribution margin, Year 2 | $259,801 | $55,319 |
| Program enrollments by month 6 | 172 | 129 |
| Unique patients, month 24 | 324 | 324 |
Change the assumptions and the 24-month forecast recalculates. Start from a deployment or move the sliders yourself. APG’s own Medicare chart count is the first thing to plug in: both programs reach their eligible ceiling inside the first year, so the size of the panel in scope, not enrollment pace, sets the census.
In Full Service, CoachCare hires, trains and manages the care managers who run the program, at a caseload of 165 patients each. Drag the slider to see the team grow with the census.
APG’s physicians, nurse practitioners and medical assistants keep doing clinical work. In Full Service the monitoring, outreach and paperwork belong to CoachCare; in a split, only the share APG hands over does.
Monitoring, outreach and documentation over 24 months, on CoachCare’s payroll.
Hired, trained and managed by CoachCare. APG would otherwise need to recruit and keep them.
The enrollment specialist working in APG’s offices and device logistics are CoachCare’s expense.
Direct integration with the eClinicalWorks system APG is moving onto, using its built-in workflows, so the program is part of the new chart from the start. Clinicians never leave the chart, and supporting documents (evidence of care, vitals and care plans) are attached to the patient’s chart every month.
eClinicalWorks integration overviewThe staff, protocols and eClinicalWorks workflow built for remote monitoring and chronic care management can take on the next programs APG’s panel qualifies for, without a second hiring plan.
APCM pays a monthly amount per patient in place of CCM, tiered by complexity, to a practice that runs the whole panel. It is not in this forecast; it is an option to weigh once the eClinicalWorks move has settled.
About one in five traditional-Medicare patients carries depression, and APG’s primary care screened about ~100 for it in CY2024. Behavioral health integration fits the same care-manager calls and the same chart.
APG already bills transitional care after some discharges, for about 50 traditional-Medicare patients in CY2024. The same care team can make the two-business-day call after every discharge, so more of them qualify, billed by APG.
Six reasons this partnership fits APG specifically, not remote care in general.
Annual wellness visits, transitional care after hospital stays, a diabetes boot camp and APG’s own between-visit program are already part of the week. CoachCare adds to that work; it does not replace the people who do it.
Built on eClinicalWorks’ own workflows. Readings, documentation and claims live in the new chart from the first weeks after the move, so the program needs no second migration later.
In Full Service, CoachCare’s care managers carry the caseload at 165 patients each, with enrollment, devices, business-hours alert triage and billing preparation on CoachCare’s payroll. Where APG’s staff run the work, they get the same platform, devices and claim automation.
APG’s clinicians set the protocols, sign the care plans and make every clinical decision. Claims go out under APG’s own billing entity and NPIs.
APG’s primary care traditional-Medicare patients average 74. Cellular devices need no home internet, no smartphone and nothing to pair, and outreach runs by phone, so no patient has to learn an app.
A 29.1 mmHg drop in Stage 2 hypertension across 2,738 patients at Cardiac Solutions in West Phoenix (case study), half the 30-day readmission rate across 26,689 patients at the same practice (case study), and zero readmissions among 450 advanced heart-failure patients at Iowa Heart (case study).
The ask: a working session to confirm APG’s Medicare chart count by payer and by office, check how each Medicare Advantage contract covers the care-management codes, decide how much of the care team APG staffs itself, and scope the eClinicalWorks integration alongside the move, before the first patient enrolls.
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