Chronic care management and remote monitoring for geriatric practices
Older adults manage more conditions, more medications and more care transitions. We give them a consistent care team between visits, in their own language, with family caregivers included when the patient wants them to be.
What we focus on with older adults
Geriatric care is less about a single reading and more about the whole picture: what the patient is actually taking, how they're getting around, and whether anything has changed at home.
Medications
A weekly review of what the patient actually takes, including over-the-counter products, with discrepancies routed to your team.
Falls
Questions about falls and near-falls on every check-in, flagged to your practice when they occur.
Heart failure and hypertension
Daily weights and blood pressure from large-display devices, reviewed every day.
Cognition and mood
Changes reported by the patient or caregiver are flagged, and standardized depression screening questions are asked.
Care transitions
A call after every hospital discharge, medication reconciliation and help scheduling the follow-up visit.
Advance care planning
Conversations about advance directives and surrogate decision makers, documented for your review.
Evidence from older adult populations
Some of the largest studies of home telehealth and transitional care were conducted in predominantly older populations.
Published results reflect specific program designs and patient populations. Outcomes for any program depend on patient selection, engagement and how escalations are acted on.
VA home telehealth
Among 17,025 veterans, mostly aged 65 or older, enrollment was followed by 25% fewer bed days of care and 19% fewer hospital admissions, with an 86% mean satisfaction score.2
Transitional care after discharge
Across 18.7 million eligible Medicare discharges, mortality in the 31 to 60 days after discharge was 1.0% among patients who received transitional care management versus 1.6% among those who did not.3
Chronic care management in Medicare
A CMS-commissioned evaluation found fewer hospitalizations and emergency department visits among beneficiaries receiving CCM.4
Diagnoses commonly referred from geriatric practices
Most older adults referred to the program have three or more chronic conditions.
| Condition | ICD-10-CM |
|---|---|
| Essential hypertension | I10 |
| Heart failure, unspecified | I50.9 |
| Type 2 diabetes without complications | E11.9 |
| COPD, unspecified | J44.9 |
| Atrial fibrillation, unspecified | I48.91 |
| Chronic kidney disease, unspecified | N18.9 |
| Unspecified dementia | F03.90 |
| Osteoarthritis, unspecified site | M19.90 |
| Age-related osteoporosis | M81.0 |
| Hyperlipidemia, unspecified | E78.5 |
| Hypothyroidism, unspecified | E03.9 |
Questions from geriatric practices
Can family members join the calls?
Yes. With the patient's permission, caregivers can join check-ins and receive updates.
What if a patient has trouble with technology?
The devices need no smartphone, app or Wi-Fi. Patients use one button and the reading is sent automatically, and check-ins happen by phone.
Which languages does the care team speak?
English, Spanish, Korean, Farsi, Russian and Armenian.
Other specialty programs
Let's talk about your patients.
A short conversation is usually enough to see whether VitalityMed is the right fit for your practice.
- We review your specialty, your patients and what you want to improve.
- You see a sample monthly summary before you commit.
- Getting started takes one onboarding call and your clinical protocols.
Patients and families can call the same number.
Request a conversation
We'll reply by phone or email. Please don't include patient health information.
References
- National Council on Aging. Get the facts on healthy aging. www.ncoa.org
- Darkins A, Ryan P, Kobb R, et al. Care Coordination/Home Telehealth: the systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions. Telemed J E Health. 2008;14(10):1118-26. pubmed.ncbi.nlm.nih.gov
- Bindman AB, Cox DF. Changes in health care costs and mortality associated with transitional care management services after a discharge among Medicare beneficiaries. JAMA Intern Med. 2018;178(9):1165-71. pmc.ncbi.nlm.nih.gov
- Mathematica Policy Research for the Centers for Medicare & Medicaid Services. Evaluation of the diffusion and impact of the Chronic Care Management (CCM) services: final report. www.cms.gov
Page last reviewed 2026-09. This page is for health care professionals and is not medical advice.