Chronic care management and remote monitoring for primary care practices
Patients with hypertension, diabetes, COPD and heart failure need attention between visits that a busy practice can't always give. Our licensed care team provides it, following your protocols, without adding work for your staff.
Where the program helps most in primary care
Every enrolled patient has one care plan built around your protocols. Home readings show how they're doing day to day; weekly calls cover medications, symptoms and the follow-up you've ordered.
Hypertension
Daily readings from a validated home cuff, reviewed against the targets you set, with adherence and side effects covered on weekly calls.
Type 2 diabetes
Home glucose readings, medication and meal routines, and reminders to keep the follow-up visits you've ordered.
Heart failure
Daily weights and blood pressure, symptom questions every week, and escalation on rapid weight gain according to your thresholds.
COPD and asthma
Pulse oximetry and symptom trends, inhaler adherence and technique, and action-plan reinforcement.
Multiple chronic conditions
A single care plan, medication reconciliation after every change, and coordination with the specialists your patient sees.
Evidence behind home monitoring and care management
Hypertension is the most common reason primary care patients are enrolled, and it's where the evidence for home monitoring is strongest.
Published results reflect specific program designs and patient populations. Outcomes for any program depend on patient selection, engagement and how escalations are acted on.
Home blood pressure telemonitoring improves control
In a cluster randomized trial of 450 adults across 16 primary care clinics, home telemonitoring with pharmacist case management lowered systolic blood pressure 10.7 mmHg more than usual care at 6 months and 9.7 mmHg more at 12 months, and the benefit persisted 6 months after the program ended.3
Chronic care management reduces acute care use
A CMS-commissioned evaluation of Medicare's CCM services found fewer hospitalizations and emergency department visits among beneficiaries receiving CCM, along with lower total Medicare spending.4
Home telehealth works at scale
Across 17,025 patients in the VA's national home telehealth program, enrollment was followed by 25% fewer bed days of care and 19% fewer hospital admissions.5
Support for your MIPS quality measures.
Weekly check-ins and monthly summaries produce the documentation many primary care measures depend on. Your team reviews it and records it in the chart.6
- #236 Controlling High Blood PressureHome blood pressure trends give your team current readings and context between visits.
- #130 Documentation of Current MedicationsWeekly calls surface medication changes, over-the-counter use and discrepancies for your team to reconcile.
- #226 Tobacco Use: Screening and CessationTobacco status is documented and positive findings are routed to your practice.
- #134 Depression Screening and Follow-UpStandardized screening questions, with positive screens flagged for your follow-up.
- #047 Advance Care PlanConversations about advance directives and surrogate decision makers, documented for your review.
- #374 Closing the Referral LoopReferrals are tracked and missing specialist reports are flagged so your team can request them.
Measure selection, eligibility and reporting stay with your practice. Credit depends on your team reviewing the information and documenting it in the patient record.
Diagnoses commonly referred from primary care
Patients typically qualify with two or more chronic conditions expected to last at least a year that put them at significant risk of decline. These are the diagnoses we see most often.
| Condition | ICD-10-CM |
|---|---|
| Essential hypertension | I10 |
| Hypertensive heart disease with heart failure | I11.0 |
| Heart failure, unspecified | I50.9 |
| Type 2 diabetes without complications | E11.9 |
| Type 2 diabetes with hyperglycemia | E11.65 |
| Atherosclerotic heart disease | I25.10 |
| COPD, unspecified | J44.9 |
| Asthma, unspecified, uncomplicated | J45.909 |
| Hyperlipidemia, unspecified | E78.5 |
| Hypothyroidism, unspecified | E03.9 |
| Obesity, unspecified | E66.9 |
| Major depressive disorder, recurrent | F33.9 |
| Generalized anxiety disorder | F41.1 |
Questions from primary care practices
Which primary care patients qualify?
Patients with two or more chronic conditions expected to last at least 12 months, or until death, that place them at significant risk of death, acute exacerbation or functional decline. We review eligibility with your team during onboarding.
Do we need to change our EHR or workflow?
No. Updates arrive through a secure, real-time portal, and your team reviews and documents them the way it would any clinical note.
Who talks to our patients?
A member of our licensed care team, speaking on behalf of your practice. The care team speaks English, Spanish, Korean, Farsi, Russian and Armenian.
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
- Centers for Disease Control and Prevention. High blood pressure facts. www.cdc.gov
- National Council on Aging. Get the facts on healthy aging. www.ncoa.org
- Margolis KL, Asche SE, Bergdall AR, et al. Effect of home blood pressure telemonitoring and pharmacist management on blood pressure control: a cluster randomized clinical trial. JAMA. 2013;310(1):46-56. pubmed.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
- 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
- Centers for Medicare & Medicaid Services. Quality Payment Program: MIPS quality measures and improvement activities. qpp.cms.gov
Page last reviewed 2026-09. This page is for health care professionals and is not medical advice.