A turnkey care-management program. No upfront investment. No new hires.
CareAtlas runs RPM, CCM, TCM, and APCM end-to-end for primary care and specialty practices — as CareAtlas Complete (we run everything, you refer), or as CareAtlas Extend (we augment your existing care-management team). Your practice stays provider of record. Your patients get the monthly contact their conditions actually require. Revenue varies by program mix, volume, and payer. Not a guarantee of income.
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The pressures compounding on community and health-system leaders
Readmissions, margins, workforce, technology. CareAtlas is built for the specific version of these problems that hospital leaders are living through.
Readmissions are expensive clinically, operationally, and financially.
Medicare spends ~$17.5 billion annually on readmissions, roughly $12 billion potentially preventable. CMS penalties under the HRRP erode margin on every avoidable return. Most post-discharge prevention work is operationally fragile — the 2-day outreach call slips, the follow-up visit gets scheduled outside the required window, and the clinically preventable readmission happens anyway.
Margins don't allow for another cost line.
Nearly half of community hospitals are operating at negative margins. Launching an in-house care-management program — navigators, technology, devices, billing staff — is not a defensible capex ask in this environment. A partnership that goes live with no upfront investment and no new hires is.
You cannot hire your way into this program.
Nursing vacancy rates are running 4–5x higher than a decade ago. The licensed care navigators needed to run a credible care-management program do not exist inside most community hospital labor markets. Outsourcing the capacity is the only realistic path.
A care-coordination layer, not another system to buy.
Hospital CIOs have more EHR modules, population-health dashboards, and care-coordination tools than their clinical staff can use. CareAtlas is not another dashboard. HealthQuilt is a coordination system that runs the program and pushes structured clinical summaries back into the EHR the hospital already uses.
One partnership. Four programs. Run by CareAtlas as provider of record.
CareAtlas Complete is the model most community and regional health systems choose. CareAtlas is provider of record through our affiliated professional corporation. The hospital refers. We enroll, deliver, document, and bill. You benefit from improved outcomes, reduced readmissions, and a partnership that goes live with no upfront investment and no new hires.
No upfront investment. No new hires.
CareAtlas Complete is a partnership model — CareAtlas capitalizes the navigators, the clinicians, the technology, the devices, and the billing infrastructure. The hospital refers. The economics align on shared outcomes, not a capex ask.
Proven where the model is hardest.
Our 145-patient cohort is 89% age 65+, 38% COPD, 24% CHF — the high-risk rural and community-hospital population where care-management programs most often fail. Results: 14.8% 30-day readmission rate against the 19% CMS benchmark — a 23% relative reduction. Under 1% voluntary discontinuation.
RPM, CCM, TCM, and APCM — run together.
Most organizations run these programs through multiple vendors or not at all. CareAtlas manages all four under one roof — maximizing per-patient reimbursement and eliminating the operational overhead of stitching programs together. The platform captures every qualifying element structurally; the claims assemble cleanly; the reporting flows back to the hospital on a cadence.
We have a model that fits.
Every organization is different. CareAtlas offers three models so you get exactly the level of support you need — from full-service to platform-only.
CareAtlas Complete
Full-service care coordination. We provide the navigators, technology, devices, enrollment, billing, and care delivery — end to end. For hospitals, CareAtlas serves as provider of record — no upfront investment required. For practices and community health centers, revenue consistently exceeds program costs.
CareAtlas Extend
Already have some care coordination staff? We augment your team with the HealthQuilt platform, device logistics, and overflow navigator support — filling gaps without replacing what works.
CareAtlas Connect
Platform-only access to HealthQuilt — our AI-assisted care coordination software, EHR integration, analytics, and compliance tools. You bring the team. We bring the technology.
Four programs.
One operating partner.
Each of these programs runs inside HealthQuilt and delivers both clinical impact and Medicare revenue. Together they form an integrated care-management program for your Medicare population.
Remote Patient Monitoring
RPM: Daily visibility into patient health
Cellular-connected devices ship directly to patients — blood pressure cuffs, glucose monitors, pulse oximeters, scales. No WiFi. No smartphone. No patient app. Daily readings are monitored by dedicated care navigators with AI-assisted alerts that catch deterioration before it becomes an ER visit.
Chronic Care Management
CCM: Consistent care between appointments
Monthly navigator check-ins, personalized care plans, medication management, and social determinant screening — all documented and billed under 99490/99491. Only about 18% of eligible Medicare discharges receive a TCM bill, even though roughly 52% of unbilled eligible discharges already had a qualifying visit within 14 days. CareAtlas helps close that gap.
Transitional Care Management
TCM: The critical 30 days after discharge
Navigator outreach within 48 hours of discharge. Medication reconciliation. Follow-up scheduling. 30 days of transition support during the window when patients are most vulnerable — and when the vast majority of billable TCM episodes go uncaptured. Only ~9% of eligible Medicare discharges result in a TCM bill, and among those unbilled, over half already had a qualifying office visit within 14 days — revenue left on the table.
Advanced Primary Care Management
APCM: The newest Medicare revenue pathway
APCM reimburses across three risk-stratified tiers — $16/mo (Level 1), $54/mo (Level 2), and $117/mo (Level 3) — with no time-tracking requirements. For a panel of 200 patients at Level 2, that's ~$129K/year in recurring revenue, billable alongside RPM.
