Focused clinical coordination for patients with one serious chronic condition.
Patients managing a single complex or high-risk chronic condition often require specialized attention and coordinated follow-up.
What our PCM program does.
Best for: patients with one qualifying serious or high-risk chronic condition.
- Provide focused care coordination for patients with one qualifying serious chronic condition.
- Support disease-specific treatment plans and ongoing clinical follow-up.
- Strengthen communication between specialists and other treating providers.
- Help patients understand and manage their conditions.
- Identify changes in patient status that may require clinical attention.
- Support continuity of care and reduce fragmentation.
Closing the loop between providers.
Complex conditions fragment easily. PCM keeps one focused line of coordination between the patient, primary care, and the specialists involved.
One update, handled end to end.
When a specialist changes the plan, every treating provider needs to know and the patient needs to understand why. This is what that looks like when it is coordinated.
- Nephrology note receivedMedication change recommended
- Care plan updatedDisease-specific plan revised
- Treating providers informedPrimary care and specialist aligned
- Patient callChange explained, questions answered
How we run PCM with your practice.
Implementation, outreach, documentation, and billing support are part of the program, so it fits around your existing team.
- Identify
Identify the right patients
We help identify patients whose single serious condition needs closer coordination than routine visits allow, and enroll them with education and consent.
- Plan
Support the disease-specific plan
Coordination follows the treating physician’s disease-specific plan, with clear follow-up intervals and goals.
- Coordinate
Keep every provider aligned
Specialist updates, medication changes, and test results are communicated to everyone treating the patient, so care does not fragment.
- Watch
Notice change early
Changes in status are identified and brought to clinical attention promptly. Interactions and time are documented for billing support.
We recognize that complex disease management requires clinical understanding, physician involvement, and a focused approach to each patient’s treatment objectives.
All services are subject to applicable patient eligibility, payer coverage, physician involvement, consent, documentation, staffing, medical necessity, and Medicare billing requirements. Reimbursement depends on applicable coding and coverage criteria.
Related programs
Considering PCM for your practice?
Schedule a complimentary practice assessment. We will look at your patient population and tell you honestly whether this program fits.