Rethinking What It Means to Be Present in Patient Care

In today’s healthcare landscape, hospitals and health systems are facing increasing pressures—staffing shortages, capacity constraints, rising financial risk, and the demands of value—based care. For organizations serving large Medicare populations, the focus has shifted from simply delivering high-quality care within hospital walls to maintaining that same standard of care after discharge and over time.

Remote patient monitoring (RPM) and chronic care management (CCM) have become essential tools for addressing these challenges, providing continuity, connection, and coordination in patient care. Implemented at scale, they can help clinical teams extend their reach, support patients between visits, and improve performance across value-based care models.

Why Now: The Challenge and the Opportunity

Large health systems today face a distinct set of pressures:

• Staffing shortfalls strain your workforce and reduce capacity to expand programs.
• Fragmented technology slows adoption across departments and systems.
• Value-based performance metrics related to readmissions, chronic disease management, and preventive care are increasingly tied to reimbursement.
• Financial risk grows with the size and complexity of patient populations under management.

At the same time, the opportunity to impact health outcomes through better post-discharge monitoring, early intervention, and ongoing engagement has never been greater.

From Episodic to Ongoing: A Model of Continuous Support

Effective RPM and CCM programs enable health systems to shift from episodic interventions to ongoing care relationships. When structured properly:

• RPM enables real-time biometric tracking of vitals outside clinical settings. Early detection of issues allows for proactive intervention, mitigating exacerbations and helping to reduce readmissions.
• CCM ensures that patients with multiple chronic conditions receive regular check-ins to provide medication reviews, ongoing education, and care coordination, all without adding burden to busy in-clinic schedules.

Together, these programs create a vast safety net that complements in-person care, providing a more complete view of the patient’s health trajectory.

Tellihealth: Care that Scales Without Compromise

Scalability depends on integration—not just technologically, but culturally and operationally. Combined together, Tellihealth’s RPM and CCM solutions allow systems to expand capacity without requiring significant new hires or workflow overhauls. For hospitals, this means:

Intelligence at Scale
Our connected RPM and CCM programs turn timely patient data into clinical insights. Providers can identify trends, meet patient needs,  escalate issues, and intervene early before a complication becomes a readmission.

Clinical Extension, Not Replacement
Tellihealth doesn’t replace your staff; rather, it supplements them. Because Tellihealth integrates with most major EHRs, nurses, care managers, and physicians can access RPM and CCM workflows from within familiar environments, with clear escalation paths and clinical decision support embedded in workflows.

Operational Simplicity. Clinical Sophistication
Tellihealth’s RPM program uses 4G cellular devices that require no apps or setup, making them easy for patients. We manage provisioning, onboarding, and engagement, so your team can focus on in-facility care. Alerts are triaged and routed to the right staff, with customizable, condition-specific content at scale.

Enterprise-Proven Results

Want proof that Tellihealth’s RPM & CCM programs can help move the needle in value-based programs? Health systems that have partnered with us to implement enterprise-level initiatives have reported:

• 63% reduction in ED utilization compared to national benchmarks
• 25% fewer inpatient admissions
• 86% of patients show improved medication adherence
• High patient engagement, with over 90% retention across remote care programs

While outcomes will vary by population and structure, these indicators demonstrate that thoughtfully integrated programs can drive meaningful clinical and operational improvements.

Use Cases Across the Care Continuum

Whether you're expanding risk-based contracts, managing high-risk populations, or modernizing transitional care, Tellihealth adapts to your goals:  

Use Case	Strategic Impact
Post-discharge RPM	Helps support Transitional Care Management (TCM) and enables early detection of complications to help reduce readmissions.
Chronic Disease CCM	Drives engagement and medication adherence for high-risk, high-cost patients.
Enterprise-wide Rollout	Standardized protocols across specialties and regions with centralized oversight.
Value-based Care Alignment	Supports benchmarks and incentives in a variety of CMS models.

The Bottom Line

The transition from hospital-based to home-based care requires more than devices and dashboards. It requires solutions that respect and support existing workflows, amplify clinical expertise, and help systems maintain the human touch at scale.

That’s Tellihealth.

With programs like RPM and CCM that help health systems adapt to evolving models of care, Telehealth helps you bring intelligent, human-centered care to thousands of patients—without burning out your team or breaking your system.

Let’s Talk

Ready to bring scalable personal care to your system?
Book a strategy session with Tellihealth today.