The ACO Playbook: Using RPM and CCM to Power Proactive Chronic Care
Chronic conditions are the biggest driver of healthcare cost, and the greatest opportunity for impact. More than 194 million U.S. adults, about 76%, live with at least one chronic disease. Yet most only see their providers a few times a year. That leaves care teams in the dark between visits and gives chronic illness far too much room to escalate. Accountable Care Organizations (ACOs) are built to solve this. But success requires more than good intentions. It demands tools that make care continuous, not episodic. That’s where chronic disease management (CDM) software comes in. Why ACOs Need a Two-Part Chronic Care Strategy To manage chronic disease effectively, ACOs need to: Monitor high-risk patients daily Stay engaged with broader panels monthly Intervene early, before the next ER visit or hospitalization This is where RPM and CCM come together as a powerful, complementary strategy. Part 1: Chronic Care Management (CCM) CCM software provides monthly support for patients with two or more chronic conditions, even those who don’t use monitoring devices. Care managers use CCM to track progress, address barriers, coordinate medications or referrals, and stay connected with patients who may otherwise fall through the cracks. How CCM Helps ACOs: Extends care to a wider chronic population Identifies social determinants of health (SDOH) Improves treatment adherence Qualifies for CMS reimbursement 💡 CMS reimburses $60–$150per patient/month, depending on time spent and complexity for non complex CCM— 2025 Medicare Physician Fee Schedule Part 2: Remote Patient Monitoring (RPM) RPM software enables care teams to track vital signs like blood pressure, weight, and glucose—automatically, from home. Daily readings flow into the platform, triggering alerts when something’s off. How RPM Helps ACOs: Identifies issues early before they escalate Reduces ER visits and hospitalizations Supports Medicare quality measures and cost benchmarks Enhances patient engagement with real-time care 📈 RPM has been shown to reduce readmissions for heart failure by up to 44%— Circulation: Cardiovascular Quality and Outcomes, 2022 💰 RPM can save $312 per patient per month in avoided acute utilization— Health Affairs, 2022 Why RPM + CCM Work Better Together When ACOs deploy RPM and CCM side-by-side, they can support a broader range of patients without overburdening their internal teams. RPM covers higher-risk patients who need daily oversight CCM covers lower-acuity patients who still benefit from structured check-ins Together, they improve outcomes, expand reach, and boost revenue This combination is particularly valuable in MSSP ACO and ACO REACH models where performance is tied to quality scores and total cost of care. Key Features to Look For As you evaluate platforms, look for solutions that offer: Unified software for both RPM and CCM built for ACO models U.S.-based clinical monitoring and care teams Configurable alerts and workflows Comprehensive Device Options Flexible wireless data transmission options – Cellular + Bluetooth Billing support for CPT codes: 99457/99458, 99490/99439 Results That Matter Whether your ACO is early in its RPM journey or looking to expand existing care management programs, combining RPM and CCM can: Reduce hospitalizations by 25–35% Improve HEDIS and MIPS quality scores Capture revenue in Medicare reimbursement Lower total cost of care and support shared savings eligibility Final Thought: Make Chronic Care Work Between Visits Chronic disease doesn’t pause between appointments—your care shouldn’t either. With the right system, ACOs can turn short visits into long-term engagement, data-driven decisions, and real outcomes. Ready to bring proactive care to life for your ACO?Let’s talk about how Vivo Care helps you scale RPM and CCM, together. Want to see how we’re bringing this strategy to life?🎥 Watch Vivo Care CEO Ryan Clark share why remote care matters now more than ever. Get a quick look at the people, vision, and mission behind Vivo Care, and how we help organizations like yours scale smarter care between visits.
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