Care that doesn't stop at the office door.
We embed care teams inside your organization to run CCM, RPM, BHI, and other VBC services. You reduce hospitalizations and readmissions and your patients stay healthier.
Who We Are
We’re care managers, nurses, data scientists, project managers, and population health people who got tired of watching patients fall through the cracks between visits. So we built a company to fix that part of healthcare.
Our Mission
Help patients live better with the conditions they have, through preventive care that treats the whole person and strengthens the relationship with their provider.
Our Values
Patients first. Whole person, not a chart. And a refusal to walk away from the hard problems in healthcare just because they're hard.
Our Vision
High-quality, person-centered care that’s there when patients need it. Day, night, weekend, whenever.
Better outcomes for your patients. Better margins for your practice.
Most organizations stitch together separate vendors for RPM, CCM, and other value-based programs, and end up leaving money, and patients, behind. We run everything under one roof, so care is coordinated and reimbursement isn’t fragmented.
Chronic Care Management
A turnkey CCM program for hospitals, health systems, ACOs, FQHCs, and multispecialty groups. We handle the implementation, the technology, the patient outreach, and the ongoing care coordination. That includes the social determinant work that quietly drives most readmissions. You stay focused on visits. We handle everything in between.
Remote Patient Monitoring
Cellular blood pressure cuffs, glucose monitors, pulse oximeters, and scales, shipped straight to the patient. No Wi-Fi. No smartphone. No app to download. Daily readings come into our care navigators, and smart alerts flag early signs of trouble before they turn into an ER trip.
Behavioral Health Integration
Integrated behavioral health support embedded into your existing workflows. We identify, enroll, and support patients with mild to moderate behavioral health needs, coordinating closely with your clinical team. Ongoing monitoring, structured care plans, and psychiatric consultation help improve outcomes while unlocking additional reimbursement.
Transitional Care Management
The 30 days after a discharge are where readmissions are won or lost. We make the interactive contact within two business days, reconcile medications, confirm the follow-up visit lands inside the required window, and surface anything that looks like it is heading the wrong way. Your team gets a documented, billable TCM episode without chasing patients down the phone.
Value-Based Care Enablement (Across Services)
Beyond individual programs, we align all services to support your broader value-based care strategy. From risk stratification and patient engagement to quality measure performance and cost containment, we help you succeed in shared savings models, ACO participation, and other VBC arrangements — without adding operational burden to your team.
Which of your patients qualify?
Two or more chronic conditions expected to last at least 12 months, placing the patient at risk of acute exacerbation or functional decline. Most panels have more eligible patients than practices expect.
Built for how healthcare actually works.
Community hospital. Multi-site network. FQHC. Value-based organization. Whatever shape your practice takes, this was designed for it. Not retrofitted from an enterprise product made for someone else.
Hospitals + Health Systems
We run RPM, CCM, TCM, and APCM. No upfront investment, no new hires. The result is fewer readmissions and a healthier and happier population.
Physician Practices
Recurring Medicare revenue per patient, without piling more onto your staff. We take on enrollment, monitoring, documentation, and billing. You stay the provider of record. The patient relationship stays yours.
Community Health Centers
One platform built for the realities of FQHCs and RHCs. Patients don’t need internet at home. Standard CPT billing is fully supported. APCM-ready from day one.
Value-Based Organizations
Sharper population health data, better triage, and measurable lift on HEDIS and Star ratings. We scale across your network to close care gaps and pull total cost of care down.
A stronger preventive care program, without the operational drag.
Our end-to-end services take the messy parts of value-based care off your plate so your team can do what it’s actually trained for.
Enrollment that actually performs
Compliant patient enrollment that averages around 50% in primary care and 40% in specialty practices. Well above what most in-house programs hit.
Programs that keep growing
Strong patient retention and steady month-over-month growth. The program you launch isn’t the program you’re stuck with. It gets bigger.
Quality support, included
MIPS and quality improvement services come with CCM at no extra cost. Not an add-on. Not a separate SOW.
Security past the baseline
HIPAA is the floor. We operate on systems and integrations that are SOC 2 Type II certified.
Help us fix the part of healthcare everyone else gave up on.
If you want a career where the work actually shows up in someone’s life — fewer hospital trips, a parent who finally has their inhaler, a patient who isn’t scared to be alone after surgery — we’d like to meet you.
Talk to a real person on our team.
Tell us a little about you and we'll get the right person on it.
