A scalable, profitable remote care service line for Family HealthCare Network: remote monitoring, chronic care management and advanced primary care management for the Medicare patients your health center already serves, billed under FHCN’s own NPIs on top of the PPS encounter and run by a CoachCare care team inside eClinicalWorks.
Medicare is changing what it pays health centers for. Four shifts are under way at once, and each one lands in the same place: the weeks between a patient’s visits. For a health center whose Medicare patients carry hypertension, diabetes and depression together, those weeks decide how the year goes.
FHCN opened in 1976 in a renovated gas station in Porterville to care for the farmworker families of the southern San Joaquin Valley. Fifty years later it runs 40 health center sites and two mobile units across Tulare, Kings, Fresno and Kern counties, and in 2025 it served 255,355 patients, 19,942 of them on Medicare. Most sites bring family medicine, internal medicine, pediatrics, women’s health and behavioral health under one roof, and many add dental, optometry and an in-house pharmacy.
A Medicare panel that has grown by nearly 5,000 patients since 2021, in which hypertension and diabetes are the norm and most patients also qualify for Medi-Cal. FHCN has been improving on the measures remote care moves, and the next gains come from what happens between visits.
Blood-pressure control at FHCN has risen every year since 2021, and 28,471 hypertensive patients were under 140/90 in 2025. Across 40,477 patients with hypertension, the next points come from home readings and medication changes between visits, which the office reading alone cannot drive.
Poor A1c control has fallen nine points since 2021, and HRSA names FHCN a National Quality Leader in diabetes health. Across 26,595 patients with diabetes, 7,924 were still above 9% or untested in 2025, and most of them carry hypertension too. Home glucose and a monthly care-management call reach them between lab draws.
FHCN screens 87% of eligible patients for depression, in HRSA’s top quartile. Remission at twelve months is the measure that lags, at 6.2%, and it is the one that depends on follow-up between visits.
Each step below added sites, services or patients. Click through the years. The next step adds the part none of them covers: daily readings and a care team between visits.
Each part of FHCN touches a patient at one moment: a medical visit, a behavioral health appointment, a pharmacy pickup, a dental chair, a hospital discharge. A remote care service line connects them, so a patient who leaves one visit is still being watched until the next one. Select any part of the health center to see what changes.
FHCN’s physicians and advanced practice clinicians set the protocols and own every clinical decision. CoachCare staffs and runs the program. Everything runs through the eClinicalWorks system FHCN already uses, from the first flag on a patient’s chart to the claim at month end.
The program starts with the panel, not a referral pad. eClinicalWorks already holds the diagnoses, vitals, labs and medications FHCN reports to HRSA every year. Patients with uncontrolled hypertension, diabetes or several chronic conditions are flagged using criteria FHCN’s clinicians set, so the right patients surface at a visit, at an annual wellness visit, or on an outreach list.
Example criteria. FHCN’s clinicians set and own the flag logic for each condition.
Patients enter at a medical visit, at their annual wellness visit, or after a hospital stay. Either way they land in the same monthly loop: office visits, care management and physiologic monitoring, each one informing the next.
BP 162/96 on three agents and an A1c above 9. The clinician places the remote care order during the visit, or at the annual wellness visit.
Cellular cuff and glucometer at home, a welcome call, and how to take a reading that counts.
99453Home averages drive medication changes month to month; the care-management call covers the other conditions.
99454 · 99457 · 99490 or G0557Office visits ↻ care management ↻ physiologic monitoring.
Flagged in eClinicalWorks when the discharge notice arrives. Devices ordered to the home.
Contact within two business days, medication reconciliation, an FHCN visit in 7–14 days.
TCM 99495 · 99496Readings start right away. The short-month device code covers the first partial month.
99453 · 99445 · 99490Office visits ↻ care management ↻ physiologic monitoring.
The clinician orders from the chart, or a CoachCare enrollment specialist working at an FHCN site enrolls the patient during the visit.
Cellular devices arrive ready to use. No Wi-Fi, no smartphone and no home internet needed, and nothing for the patient to pair.
The patient’s assigned care manager walks through the device, the routine, and who to call. The language plan for Spanish-speaking patients is set with FHCN before launch.
Readings reviewed, outreach logged, care plan updated, escalations routed. Repeats every month.
From the enrollment flag in eClinicalWorks to the first billable day of service. Enrollment status is visible in the chart the whole way through, at every site.
Readings that settle are logged in the chart and visible to the clinician without paging anyone.
Out-of-range readings get a retake and symptom check first. A confirmed trend goes to the clinician or nurse each site designates, in eClinicalWorks, with the readings and a recommended next step attached.
Chest pain, new shortness of breath or stroke signs reported on a call: the care team calls 911 with the patient on the line, then notifies the site. A critical reading on its own goes to the site. This cannot be configured away.
At month end, three things come out of the program: clean claims in eClinicalWorks, an operational report for FHCN’s leadership, and a clinical outcomes report that lines up with the measures FHCN reports to HRSA.
The integration creates the claims automatically. No one builds a claim by hand, patient by patient, month by month.
A monthly scorecard for the health center. Sample below at the modeled month-12 census.
A 24-month forecast for an FHCN remote care service line: remote monitoring, chronic care management and advanced primary care management across the Medicare panel, priced at the CY2026 national rates health centers bill, on top of the PPS encounter, with every patient priced at the Medicare amount. Alongside it, what the program does for patients and for the people who run it.
Four visits a year leave 361 days with no data. RPM bills only when a patient takes readings on at least 16 days in a month, so an enrolled patient gives the care team at least 192 days of readings a year.
Hypertension is the most common chronic condition at FHCN and the one home monitoring moves fastest. Home averages give the care team a monthly reason to adjust medication, and the documented result is the home number, not one rushed office reading.
Cardiac Solutions, a physician-owned practice with three offices, put 2,738 patients on CoachCare RPM with home blood-pressure monitoring.
FHCN reports clinical quality to HRSA every year, and its clinicians have taken part since 2021 in a Medicare Shared Savings Program ACO, now on the Enhanced track, that is scored on an overlapping set. Most of these measures depend on work this program does every month. FHCN bills these codes claim by claim for every Medicare patient, whether or not the patient is assigned to the ACO, and the same monthly work counts toward the ACO’s quality score and its spending benchmark. Select a measure to see how.
Monitoring the panel every day tells the health center who needs to be seen now, which the schedule alone cannot. Patients surface from their home data before they come in sicker.
When an FHCN patient goes home from the hospital, the next 30 days decide whether they come back. Transitional care management pays for that month; remote monitoring and care management carry the patient past it.
Flagged in eClinicalWorks for post-discharge monitoring.
A call within two business days and medication reconciliation.
Readings start right away. 99445 bills the short first month.
Monthly RPM with CCM or APCM while it adds value.
Daily weight and BP from day two, three touches inside two weeks, a cardiology referral when the trend returns.
Oxygen saturation and symptoms after an exacerbation, with a quick visit before a return trip to the emergency department.
Glucose and BP while medications change after a stay, and a fluid check for patients with CKD.
Patients who carry hypertension or diabetes into a behavioral health admission stay on their readings and their monthly call until the follow-up visit.
Every code the service line can bill, at the CY2026 national Medicare rates health centers bill. Since January 1, 2026, a health center bills each of these on its own, in addition to the PPS encounter for the visit. Build a patient-month to see what one patient is worth.
CY2026 Medicare Physician Fee Schedule, national non-facility amounts: the rate a federally qualified health center bills for these codes at every site, in addition to the PPS encounter. Medi-Cal pays health centers per visit and does not pay them separately for remote monitoring, so the forecast counts Medicare only, including the Medicare share for dual-eligible patients. Only one device code (99454 or 99445), one first-tier management code (99457 or 99470) and one care-management program (CCM or APCM) bill per patient per month. About 37% of Medicare beneficiaries in Tulare County are in Medicare Advantage, and 49% in Fresno County. Those plans must pay at no less than the Medicare rate, a floor; individual contracts set their own terms for the care-management code families, and the forecast prices every patient at the Medicare amount.
FHCN can start with remote monitoring and keep Medicare care management for later or for its own care coordinators, or run all three programs through CoachCare. Either way the program is net-positive. Select a deployment to redraw the charts.
| Full service line | Year 1 | Year 2 | 24 months |
|---|---|---|---|
| Net reimbursement | $2,213,797 | $8,432,923 | $10,646,720 |
| CoachCare cost (program and integration fees) | $1,304,641 | $4,818,384 | $6,123,024 |
| Net to FHCN after fees | $909,156 | $3,614,539 | $4,523,696 |
| Margin to FHCN | 41.1% | 42.9% | 42.5% |
| By program: remote monitoring $4,505,965 · chronic care management $3,581,413 · advanced primary care management $2,559,342 in net reimbursement. The remote-monitoring deployment alone runs at a 42.2% margin. Month 1 runs −$2,184 while implementation and the eClinicalWorks setup post against a census still ramping; net-positive from month 2. Fee-for-service reimbursement only, in addition to the PPS encounter; no shared-savings or grant dollars are in these figures. | |||
Two ways to run the same program, on the same Medicare panel, the same national rates and the same 24 months. Full Service is the forecast on this page: devices, software and the CoachCare care team. Self Service gives FHCN the same devices and software inside eClinicalWorks and leaves the care team, enrollment and the monthly minutes to FHCN’s own staff, the way its care coordinators run Enhanced Care Management today.
Self Service runs the same enrollment engine with two things an in-house team carries: enrollment at three-quarters of the pace, because nobody’s whole job is enrolling, and a quarter fewer billable remote-monitoring and chronic-care minutes, because time-based codes pay only when the minutes are logged every month. Software and device fees are at list price, and FHCN employs the clinical minutes.
| 24 months | Full Service | Self Service |
|---|---|---|
| Net reimbursement | $10,646,720 | $7,206,923 |
| CoachCare fees | $6,123,024 | $1,228,586 |
| FHCN staffing (care team, program lead, enrollment role) | $0 | $3,038,626 |
| Net to FHCN | $4,523,696 | $2,939,711 |
| Program enrollments by month 6 | 1,855 | 1,391 |
| Net to FHCN, Year 1 · Year 2 | $909,156 · $3,614,539 | $492,419 · $2,447,291 |
Change the assumptions and the 24-month forecast recalculates. Start from a deployment or move the sliders yourself. FHCN’s own Medicare chart count by payer is the first thing to plug in.
CoachCare hires, trains and manages the care managers who run the program, at a caseload of 165 patients each. Drag the slider to see the team grow with the census.
FHCN’s physicians, physician assistants, nurse practitioners, nurses and medical assistants keep doing clinical work. The monitoring, outreach and paperwork belong to CoachCare, at a time when every health center is competing for the same nurses.
Monitoring, outreach and documentation over 24 months, on CoachCare’s payroll.
Hired, trained and managed by CoachCare. FHCN would otherwise need to recruit and keep them.
The enrollment specialist working at FHCN sites and device logistics are CoachCare’s expense.
Direct integration with the eClinicalWorks system FHCN already runs at every site. Clinicians never leave the chart, and supporting documents (evidence of care, vitals and care plans) are attached to the patient’s chart every month.
eClinicalWorks integration overviewThe staff, protocols and eClinicalWorks workflow built for remote monitoring and care management can take on the next programs FHCN’s patients qualify for, without a second hiring plan.
Depression remission at twelve months is the UDS measure with the most room to move. Monthly behavioral health integration fits the same care-manager calls and the same chart, and it is the program built for remission.
A call within two business days of every discharge and a visit inside two weeks, run on the same escalation engine and billed by FHCN.
Medicare now pays for community health workers’ time addressing the social needs that get in the way of treatment. The same care-plan record and monthly cadence carry it.
Six reasons this partnership fits FHCN specifically, not remote care in general.
FHCN already coordinates care month to month for its highest-need Medi-Cal patients and runs a Navigation Center with nurse triage. This program brings the same discipline to the Medicare panel, adds daily readings, and Medicare pays for it.
Readings, documentation and claims live in the eClinicalWorks chart FHCN already uses at all 40 sites, and enrollment status is visible at every site.
CoachCare’s care managers carry the caseload at 165 patients each. Enrollment, devices, business-hours alert triage and billing preparation are on CoachCare’s payroll, and fees are per active patient per month, with no capital outlay.
FHCN’s physicians and advanced practice clinicians set the protocols, sign the care plans and make every clinical decision. Claims go out under FHCN’s own billing entity and NPIs, separate from the PPS encounter.
Cellular devices that need no home internet and nothing to pair, for patients in Three Rivers, Pixley and Squaw Valley as much as in Visalia and Fresno. Nearly a third of FHCN’s patients have limited English, so enrollment, device instructions and outreach are scoped with FHCN for Spanish-speaking patients before the first patient enrolls.
A 29.1 mmHg drop in Stage 2 hypertension across 2,738 patients at Cardiac Solutions (case study), half the 30-day readmission rate across 26,689 patients at the same practice (case study), and zero readmissions among 450 advanced heart-failure patients at Iowa Heart (case study).
The ask: a working session with FHCN’s leadership to confirm the Medicare chart count by payer (traditional Medicare, Medicare Advantage and dual-eligible) and ACO assignment, walk through how care coordination and the Navigation Center run today, review what the ACO partner already provides for care management, and scope the eClinicalWorks workflow and the first sites.
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