RPM and CCM: Specialist Referrals

A 70-year-old woman suffering from hypertension, diabetes, obesity, and osteoarthritis agreed to Remote Patient Monitoring (RPM) and Chronic Care Management (CCM) services.

The patient required support with appointment management for her PCP and specialists. Elevated RPM readings prompted immediate clinical intervention (telehealth visit), resulting in medication adjustments that prevented unnecessary hospitalization. Due to persistent poor dietary habits, the patient was directed to a nutritionist for guidance.

Assistance with Medicaid benefits and entitlements was requested, leading to a referral to a social support service provider. Medicaid transportation arrangements were made for appointments. The ongoing focus remains on actively monitoring RPM and promoting medication adherence to prevent hospital admissions.