Nephrology practices face a growing challenge: how to deliver continuous, proactive care to complex CKD patients while managing limited staff capacity and increasing value-based care requirements.

That’s where Chronic Care Management (CCM) and Remote Patient Monitoring (RPM) come in. When thoughtfully implemented, these programs streamline workflows, empower clinical teams, and improve patient outcomes.

Here are five practical steps to make CCM and RPM work seamlessly in your nephrology practice.

Step 1: Start with the Right Devices

Daily monitoring begins with reliable data. For nephrology, that means blood pressure monitors, glucose meters, weight scales, and SpO₂ devices.

• Avoid Bluetooth/Wi-Fi devices. They require patient setup, ongoing syncing, and reliable internet access—barriers that can create frustration and non-compliance, especially in rural or lower-connectivity settings.
   
• Look for 4G cellular-enabled devices. These transmit automatically anywhere with cell service, ensuring consistent, reliable data without patient burden.

The Goal: Reduce missed data, staff callbacks, and gaps in patient logs.

Step 2: Integrate Directly with Your EHR

Data has little value if it lives outside your workflow. Look for solutions that integrate directly into your EHR, ensuring that vitals flow seamlessly into patient charts where providers already work.

• This reduces duplicate documentation—nurses shouldn’t spend time re-typing values or scanning logs. 
   
• Integration also helps ensure compliance for billing and audit purposes.

The Goal: Efficiency for staff, cleaner documentation, and better support for reimbursement.

Step 3: Extend Your Care Team with Clinical Support

RPM and CCM can feel overwhelming without extra hands. Monthly check-ins, medication reconciliation, and daily data review take time that in-house teams often don’t have. That’s where dedicated staff support makes the difference.

• Monthly CCM calls: Handle care coordination, medication reconciliation, and patient check-ins to keep patients engaged and improve adherence.
   
• Daily RPM triage: Nurses review data and escalate only when intervention is needed.

The Goal: Free up in-office staff while keeping patients consistently supported between visits. The practice saves hours of manual outreach, while every role works at the top of their license.

Step 4: Align with Value-Based Care Programs

Nephrology practices operate under increasing pressure to meet Kidney Care Choices (KCC) and other CMS quality benchmarks.

• CCM and RPM both generate reimbursable revenue through CPT codes (99453, 99454, 99457, 99458, 99490, 99439).
   
• More importantly, they support quality metrics by reducing avoidable admissions, improving blood pressure control, and limiting emergent dialysis starts.
   

The Goal: Gain both a clinical and financial advantage under value-based contracts by leveraging CCM + RPM.

Step 5: Scale with a Partner Who Makes It Simple

The final step is choosing a partner who can bring all of these elements together without adding complexity.

Tellihealth is the largest U.S. provider of Remote Intelligent Care, supporting more than 100,000 patients nationwide. Our model combines:

• 4G cellular-enabled devices shipped directly to patients,
   
• logistics and onboarding support,
   
• direct EHR integration, and
   
• U.S.-based clinical staff for CCM and RPM.

The Result: Nephrology practices can grow their CCM/RPM programs confidently—whether they manage 100 patients or 1,000—knowing workflows will stay streamlined and outcomes will improve.

Conclusion

Seamless CCM/RPM integration doesn’t just improve patient care—it reshapes workflows so nephrology practices can thrive in today’s environment.

By following these five steps—choosing the right devices, integrating data, extending your care team, aligning with value-based care, and partnering for scale—you’ll create a connected model of care that benefits both your patients and your staff.

👉 Want to go deeper? Download our free ebook:
 Seamless Integration – How Nephrology Practices Streamline Workflows with CCM/RPM