How RPM and CCM connect care in multi-specialty practices

Fragmentation doesn’t happen in the exam room—it happens in the space between visits and between specialties. Patients living with cardiometabolic conditions rarely fit neatly into one lane: a cardiology medication change can influence glucose control, while an endocrine adjustment can impact fluid status and blood pressure. Remote patient monitoring (RPM) paired with chronic care management (CCM) closes these gaps, creating a continuous, coordinated experience that patients can actually feel.

Below, see how multi-specialty practices are combining Tellihealth’s RPM and CCM solutions to connect specialty silos—cardiology, endocrinology, nephrology, pulmonology—unifying care and simplifying workflows.

Why RPM + CCM are the bridge between specialties

RPM collects readings at home (e.g., blood pressure, weight, glucose) and surfaces actionable insights in real-time.
CCM provides ongoing human follow-through—monthly outreach, education, and coordination—so insights turn into timely care.

Together they:

• Unify the daily patient story across specialties with shared device data, consistent thresholds, and a common alert language.
• Accelerate safe interventions by routing the right signals to the right clinician and documenting the plan for all to see.
• Sustain engagement with structured, recurring CCM touchpoints that reinforce goals, self-management skills, and medication adherence.
   

What this looks like with Tellihealth

Tellihealth RPM Foundation

• 4G cellular blood pressure cuffs, weight scales, and glucometers—pre-configured so data flows without Wi-Fi, apps, or set-up headaches.

• Configurable alerts and trend flags (e.g., 3-day average BP, 5-lb/5-day weight gain, fasting glucose outliers).

• Patient-friendly onboarding and multilingual education materials to improve first-14-day adoption and sustained readings.

   

Tellihealth CCM Layer

• Dedicated clinical team for monthly outreach, goal setting, medication reinforcement, and social needs screening.
• Cross-specialty coordination: shared updates, task routing, and clear “who does what next” notes.
• EHR-friendly workflows to keep documentation with the patient record and reduce duplicate data entry.
   

In short: Devices + data (RPM) identify what’s changing; people + process (CCM) ensure the right specialty acts—fast—and everyone sees the plan.

Cross-specialty scenario #1: Cardiology + Endocrinology

Patient profile: John, age 72, HFpEF and type 2 diabetes.
Devices: Cellular BP cuff, weight scale, glucometer.

Signals that matter

• Weight: +5 lbs over 5 days → early fluid retention
• BP: AM average 170/90 across 3 days
• Glucose: Fasting values drifting from 120–130 to 160–180 mg/dL

Coordinated response

1. RPM alert fires for weight gain and BP trend.
    
2. RPM nurse calls John the same day → performs assessment and confirms bilateral pitting ankle edema, high salt meals over the weekend, and missed dose of diuretic x2 due to intolerance to frequent urination.  RPM nurse notifies both the partnered provider and the Tellihealth CCM nurse for follow-up.
    
3. Cardiology receives a concise update and recommends a short diuretic adjustment plus 48-hour follow-up weights.
    
4. Endocrinology reviews the same note and flags that recent steroid injection for knee pain may be pushing glucose up → temporary insulin correction plan + dietary coaching from CCM.
    
5. CCM nurse contacts John to provide education on timing of diuretic dosing to reduce nocturia, and dietary adjustments for fluid. She also connects him with medication adherence reminder tools and works with him to ensure weight return to baseline and resolution of symptoms.
    

Why this works

• Signals are shared once; actions are clear.
• Each specialty within the practice sees context, not just numbers.
• The patient experiences one plan, not two disconnected instructions.
   

Tellihealth in Action

• Configurable thresholds ensure weight/BP trends route to cardiology first, while glucose drift prompts endocrine review.
   
• One coordinated outreach from Tellihealth’s CCM team prevents duplicate calls and mixed messages.
   

Cross-specialty scenario #2: Nephrology + Primary Care (with Cardiology in the loop)

Patient profile: Annie, CKD stage 3, hypertension, and hyperlipidemia.
Devices: Cellular BP cuff, weight scale.

Signals that matter

• BP: Evening readings >150/95 4 of the last 7 days
• Med timing: Annie admits to taking ACE inhibitor “whenever I remember”
   

Coordinated response

• CCM nurse uses motivational interviewing to co-create a routine for Annie (take meds with evening TV show).
• Primary care adjusts dose timing and adds a low-dose thiazide.
• Nephrology confirms renal function monitoring schedule and target BP (<130/80) to protect kidney function.
• Cardiology (cc’d) notes improved morning BP within 10 days; no additional changes needed.
   

Tellihealth in action

• Adherence-aware coaching during CCM calls turns “non-compliance” into a workable habit for Annie.
• Shared plan updates reduce the “who changed what?” email chain across clinics.

How to put the pieces together for a unified patient experience

1. Agree on shared thresholds and roles
   Define what triggers specialty review (e.g., weight gain rules for HF; fasting glucose ceilings for diabetes) and who acts first.
    
2. Standardize alert notes
   Use a consistent note template—recent trend, suspected driver (meds, diet, infection), recommended action, and patient preferences.
    
3. Schedule CCM as the glue
   Reserve monthly CCM time for reinforcement: med reconciliation, social needs, home barriers, and education tailored to what RPM surfaced.
    
4. Document once, for everyone
   Keep plans visible to all involved clinicians; avoid parallel shadow records.
    
5. Close the loop with patients
   Every change gets a plain-language summary: what changed, why it matters, what to watch for, when we’ll check back.

A better patient experience, not just better data

When patients experience a single plan with timely check-ins, confidence goes up and risk goes down. RPM surfaces what’s changing; CCM turns that information into coordinated, human care.

Interested in connecting your multi-specialty practice with one RPM/CCM workflow?
Schedule a Demo