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Emergent Healthcare

Chronic Care Management Services

The care that happens between appointments — handled by a familiar voice.

Care carries on in the weeks between appointments, and our Value Care team works inside exactly that window. A familiar voice checking in, keeping the plan moving forward, and passing everything it finds straight back to your care team.

Request your free consultation →See how it works
  • Monthly Check-Ins
  • Bilingual Team
  • HIPAA-Compliant

Meet the team · 1 min

Nathan Alpízar

Value Care Team Lead

  • How we stay with patients between visits
  • Why follow-up keeps patients in your care
  • HIPAA compliance, audited and verified

The problem we solve

The weeks between appointments are where care is lost

  • Patients disappear between visits

    Nobody calls, nothing changes, and the next appointment never gets booked.

  • Preventive care that never happens

    Screenings and vaccinations come due and quietly pass by.

  • Readmissions nobody saw coming

    Post-discharge is where recovery is won or lost — and where most practices have no reach.

What's included

One division, the whole operation

Chronic Care Management Outsourcing — Monthly Check-Ins

Monthly one-on-one check-ins with every enrolled patient — the core of an outsourced chronic care management program, run by people your patients recognize. It works as an extension of your care coordination, not a parallel track: everything we find goes straight to your care team.

  • Monthly one-on-one calls with every enrolled patient
  • Chronic condition follow-up and education
  • Findings passed straight to your care team
  • Documented in full, every time
Learn more

Enrollment, Consent and Program Setup

We identify eligible patients from your panel, handle outreach and consent, and set the program up inside your existing workflows — so it starts producing check-ins in weeks, not quarters.

Medication Review & Follow-Up

Medication use reviewed on every check-in, with findings reported to your team the same day. When the barrier is the pharmacy itself — an authorization stuck, a refill that never happened — it moves to the division built for exactly that.

Authorizations, refills and adherence run in our Pharmacy Support Division →

Replaces: silence between appointments. Ask about this →

Preventive Care & Patient Outreach Services

Outreach for screenings, vaccinations and preventive visits that are coming due — before they quietly pass by.

  • Screening and vaccination outreach
  • Preventive visit reminders
  • Care gap closure campaigns
  • Scheduling handled on the same call
Learn more

Preventive Care Outreach That Closes Gaps

Screenings, vaccinations and preventive visits tracked against what each patient is due for — with outreach that books the appointment on the same call, not a letter asking them to call back. Care gaps close during the year, not in the year-end report.

Replaces: care gaps found at year-end reporting. Ask about this →

Post-Discharge & Patient Follow-Up Services

Post-discharge calls that stay with the patient through the whole recovery, not just the first 48 hours.

  • Post-discharge calls through full recovery
  • Medication review with findings reported
  • Escalation to the care team when needed
  • Transitional care support
Learn more

Post-Discharge Follow-Up Calls

The first call lands within 48 hours of discharge — medications reconciled, warning signs reviewed, the follow-up visit confirmed. Then the calls continue through the whole recovery, because most readmissions happen after the first week, when everyone else has stopped calling.

Transitional Care Management Services

For practices running TCM, we operate the program’s contact schedule end to end and coordinate it with chronic care management, so a patient leaving the hospital moves from one program to the other without falling between them.

Replaces: readmissions nobody saw coming. Ask about this →

Resources & Assistance Navigation

Help reaching transportation, assistance programs and community resources — the practical barriers that quietly end treatment plans.

  • Transportation coordination
  • Assistance program navigation
  • Community resource referrals
  • Barriers documented and reported
Learn more

Replaces: plans that fail for non-clinical reasons. Ask about this →

Who uses this division

  • Family Medicine
  • Internal Medicine
  • Cardiology
  • Endocrinology
  • Geriatrics
  • Nephrology
  • Primary care · Cardiology · Endocrinology · Geriatrics

Guaranteed in the contract

The numbers this division answers for

  • PATIENT SATISFACTION

    0/5

    Industry 3.8/54.9/5 guaranteed

  • PATIENT FOLLOW-THROUGH

    0%

    No industry benchmark100% guaranteed

  • FIRST-CONTACT RESOLUTION

    0%

    Industry 68%95% guaranteed

FROM SIGNATURE TO RESULTS

How we go on call for your practice

  1. 01

    Free consultation

    We go through your call volume, your current numbers, your languages and your hours. No cost and no commitment.

  2. 02

    Transition

    We coordinate with your current team, your systems and your insurers. Someone calling on the day of the switch hears the same warm voice they always did.

  3. 03

    Reporting

    Daily oversight, and a monthly report showing exactly how many patients were reached.

FAQ

Before you ask — answered

What is chronic care management?

A program of ongoing, non-face-to-face care for patients with chronic conditions: monthly check-ins, medication review, care coordination and follow-up between appointments — designed to keep the care plan moving forward.

How is this different from transitional care management?

Transitional care management covers the weeks right after a discharge. Chronic care management is continuous, month after month. We run both, and coordinate them so a patient leaving the hospital does not fall between the two.

How much does chronic care management outsourcing cost?

It depends on how many patients you enroll and what the program covers. Chronic care management is a reimbursable program under many payers, so a properly enrolled panel typically covers the cost of running it. The free consultation reviews your panel and returns specific numbers.

Who makes the calls — nurses or agents?

Trained patient care specialists, working from your protocols, in the patient’s language. Anything clinical is escalated to your care team the same day: our specialists follow up; they do not diagnose.

Do you make post-discharge follow-up calls?

Yes — starting within 48 hours of discharge and continuing through the whole recovery. Medications are reconciled, warning signs reviewed and the follow-up visit confirmed, with anything concerning escalated to your team immediately.

Do your specialists work under our protocols?

Yes. Every account is configured to the way your practice already works, and everything our team finds goes straight back to your care team.

Which patients qualify?

That depends on your program and payer requirements — typically patients with two or more chronic conditions. We review your panel during the free consultation and identify who is eligible.

NEXT STEP

Put this division on call for your practice.

Somewhere in your waiting room there is a patient who found you because the phone was answered. Let’s talk about how to make that every patient. Free, personalized, and no commitment.

✓ A member of our team replies directly, usually the same business day.

Free · Personalized · A member of our team replies directly, usually the same business day.

Chronic Care Management Services | Value Care | Emergent Healthcare