Hospital-at-home programs are a new way of delivering healthcare that puts patient outcomes, operational efficiency, and financial sustainability first. More health systems are creating the largest hospital-at-home programs that work because of better technology and payment systems that support remote care.
What are care managers? Care managers are licensed healthcare professionals who play a critical role in coordinating and supporting patient care, especially for individuals with ongoing health conditions. They work closely with patients, providers, and care teams to develop personalized care plans, ensure continuity of care, and address clinical, social, and emotional needs. In chronic care management (CCM) programs, care managers deliver consistent, non-face-to-face support to help patients manage long-term conditions, improve adherence, and reduce hospital readmissions.
Transitional care is one of the most vulnerable points in a patient’s journey, and getting it wrong can quickly lead to complications, readmissions, and higher costs. CPT codes 99495 and 99496 were created specifically to recognize the time, coordination, and clinical judgment required to safely guide patients from hospital or facility discharge back to their home or community setting.
In 2026, the healthcare industry focused on value-based models, hybrid care delivery, and has undergone significant digital transformation than ever before. Remote Patient Monitoring (RPM) and Chronic Care Management (CCM) are playing a crucial role in improving patient outcomes, encouraging better patient engagement, and opening up new and reimbursable revenue opportunities via Centers for Medicare & Medicaid Services billing codes, also called CMS CPT Codes.
Chronic disease management has become the defining challenge of the U.S. healthcare system. More than six in ten Americans live with at least one chronic condition, and four in ten live with two or more. These patients account for the vast majority of healthcare spending, utilization, and clinician workload. Yet the dominant care model remains episodic, visit-driven, and reactive.
Patient-centered care is one of the most important ideas shaping how healthcare is delivered today. Patient-centered care puts the person, not the illness, at the center of every clinical interaction. This approach is a change from health systems that are moving away from episodic, provider-driven models.
Instead of saying, “What is wrong with this patient?” Patient-centered care asks, “What is most important to this patient?” This difference changes the way care is planned, given, and judged in a big way.
Patient-centered care is one of the most important ideas shaping how healthcare is delivered today. Patient-centered care puts the person, not the illness, at the center of every clinical interaction. This approach is a change from health systems that are moving away from episodic, provider-driven models.
Instead of saying, “What is wrong with this patient?” Patient-centered care asks, “What is most important to this patient?” This difference changes the way care is planned, given, and judged in a big way.
For a long time, Medicare payments have been based on the idea that care happens during visits to the doctor. Payment, documentation, and care delivery all relied on evaluation and management codes, procedures, and encounters. As Medicare moves toward continuous, outcome-based care, it will only work if the right operational foundation is in place. The ACCESS Model—Advancing Chronic Care with Effective, Scalable Solutions—was created to fill those gaps.
Through the introduction of Remote Patient Monitoring (RPM) and Remote Therapeutic Monitoring (RTM) into the healthcare system across the U.S., significant advancements have been made in remote care. The primary measurement used to evaluate the impact of RPM and RTM on patient care and treatment remains unchanged, i.e., patient adherence. Though several advancements in remote care management took place right from its inception to date, nothing impacts or will impact patient adherence in any way.
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