A scalable, profitable remote care service line for Arkansas Family Care Network: remote monitoring for the heart failure and kidney disease patients your seven primary care clinics already know, billed under your own NPIs and run by a CoachCare care team inside eClinicalWorks
Medicare is changing what it pays primary care 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 network whose sickest Medicare patients live with heart failure or kidney disease, those weeks decide how the year goes.
Arkansas Family Care Network is a physician-owned network of family medicine clinics around Little Rock. Its oldest practice, Little Rock Family Practice, has been seeing patients for more than 60 years. Twenty-six adult primary care clinicians (18 physicians, 7 nurse practitioners and a physician assistant) work across seven clinics in Little Rock, Bryant and Hensley, all on one eClinicalWorks system. Their traditional-Medicare patients average 74 years old and carry a CMS risk score of 1.02. Nearly three in four have hypertension and one in four has diabetes. The network bills inside an Enhanced-track Medicare Shared Savings Program ACO, completed about 5,450 annual wellness visits in CY2024, and already runs transitional care after hospital stays, with care coordinators, a registered dietitian and a pharmacist at Little Rock Family Practice.
An older Medicare panel, average age 74, in which hypertension and high cholesterol are the norm, one patient in four has diabetes and about one in five has chronic kidney disease.
74% of the network’s traditional-Medicare patients carry a hypertension diagnosis, and most heart failure and kidney patients are among them. Home readings catch what one office reading misses and let the care team adjust medication month to month instead of at the next visit.
19% of the network’s traditional-Medicare patients have chronic kidney disease, usually alongside hypertension and often diabetes (25% of the panel). Blood pressure control slows the disease, and every dose change needs a kidney lab after it.
13% carry a heart failure diagnosis, 29% ischemic heart disease and 16% atrial fibrillation. Daily weight shows fluid building days before breathlessness brings the patient to an emergency department.
Each step below added clinics, clinicians or a new way of being paid for primary care. 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 AFCN touches a patient at one moment: an office visit, a wellness visit, a care coordinator’s call, a pharmacist’s review, 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 network to see what changes.
AFCN’s clinicians set the protocols and own every clinical decision. CoachCare staffs and runs the program. Everything runs through the eClinicalWorks system all seven clinics already share, 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. Patients with heart failure or chronic kidney disease are flagged, highest risk first, using criteria AFCN’s clinicians set, so the right patients surface at a chronic-care visit, at an annual wellness visit, after a discharge or on an outreach list.
Example criteria. AFCN’s clinicians set and own the flag logic for each condition.
Heart failure and kidney patients enter at an office visit or after a hospital stay. Either way they land in the same monthly loop: office visits, care-team calls and daily readings, each one informing the next.
Select a patient to open the example; select it again to close it.
Heart failure, weight up 3 lb since the last visit and BP 146/88 on two agents. The clinician places the remote care order before checkout.
Cellular scale and BP cuff at home, a welcome call by phone, and a morning routine: weigh, then take a reading.
99453Weight catches fluid early; home BP averages guide heart-failure medication changes between visits.
99454 · 99457Office visits ↻ care-team calls ↻ daily readings.
Flagged in eClinicalWorks when the discharge notice arrives. Scale and cuff ordered to the home.
The clinic’s own team calls within two business days and books the follow-up visit, as it does today.
Readings start right away. The short-month device code covers the first partial month.
99453 · 99445Office visits ↻ care-team calls ↻ daily readings.
CKD stage 3b, eGFR down from 44 to 38, office BP 154/90 on two agents. The clinician orders home BP monitoring at the visit.
Cellular BP cuff at home and a welcome call on how to take a reading that counts.
99453Home averages drive dose changes, and the kidney labs that follow each change are ordered on schedule.
99454 · 99457Office visits ↻ care-team calls ↻ daily readings.
The clinician orders from the chart, or a CoachCare enrollment specialist working in the clinic enrolls the patient during the visit.
Cellular devices arrive ready to use. The patient needs no Wi-Fi, smartphone or home internet, and has nothing to pair.
The patient’s assigned care manager walks through the device, the routine, and who to call. The routine is set to fit the patient’s day.
Readings reviewed, calls logged, escalations routed. It 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 clinic.
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 clinic 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 clinic. A critical reading on its own goes to the clinic. This cannot be configured away.
At month end, three things come out of the program: clean claims in eClinicalWorks, an operational report for the network’s leadership, and a clinical outcomes report for the clinicians.
CoachCare is the only care-management application integrated with eClinicalWorks that creates claims automatically. No one builds a claim by hand, patient by patient, month by month.
A monthly scorecard for the network. Sample below at the modeled month-12 census.
A 24-month forecast for an AFCN remote care service line: remote monitoring for the network’s heart failure and kidney disease patients, on traditional Medicare and Medicare Advantage, priced at Arkansas’s CY2026 Medicare rates with every patient priced at the Medicare amount, alongside what the program does for patients and for the people who run it.
Two chronic-care visits a year leave 363 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.
Most heart failure and kidney patients also carry hypertension, and it is the condition 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 cardiology practice with three West Phoenix offices, put 2,738 patients on CoachCare RPM with home blood-pressure monitoring.
AFCN’s clinicians take part in an Enhanced-track Medicare Shared Savings Program ACO, which is scored on a fixed set of quality measures. Three of them turn on what happens to heart failure and kidney patients between visits. Select a measure to see how.
Daily readings tell the network which patients need a visit now, whatever the schedule says. Patients surface from their home data instead of coming in sicker.
Twelve of the network’s clinicians already bill transitional care after hospital stays. The 30 days after discharge decide whether a patient comes back, and remote monitoring carries the patient through them and past them.
Flagged in eClinicalWorks for post-discharge monitoring.
The clinic’s own transitional-care call within two business days.
Readings start right away. 99445 bills the short first month.
Monthly RPM for as long as it helps the patient.
Daily weight and BP from day two, a call on any gain of 2 to 3 lb, and a cardiology referral when the trend returns.
Blood pressure while medications change after a stay, and a lab ordered after each dose change.
About 44% of heart failure patients also have kidney disease. After a diuretic change, weight and blood pressure show which way the balance is tipping.
Every remote monitoring code the service line bills, at CY2026 Medicare rates for Arkansas. Build a patient-month to see what one patient is worth.
CY2026 Medicare Physician Fee Schedule, non-facility, Arkansas locality 13, statewide (Novitas Solutions, MAC 07102). Only one device code (99454 or 99445) and one first-tier management code (99457 or 99470) bill for a patient in a given month. About 46% of Medicare beneficiaries in Pulaski and Saline counties are in Medicare Advantage. Those plans cover these Part B services and pay them on each plan’s own contract terms; the forecast prices every patient at the Medicare amount.
CoachCare runs remote monitoring for the network’s heart failure and kidney disease patients on traditional Medicare and Medicare Advantage. Contribution margin runs −$5,635 in month 1 while the program ramps; positive from month 2.
| Remote monitoring | Year 1 | Year 2 | 24 months |
|---|---|---|---|
| Patients enrolled, end of period | 994 | 994 | 994 |
| Contribution margin | $208,136 | $440,548 | $648,684 |
| No shared-savings dollars are in these figures. | |||
Change the assumptions and the 24-month forecast recalculates. Remote monitoring reaches every heart failure and kidney patient expected to enroll by month 11, so panel size moves the answer most, and AFCN’s own Medicare chart count 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.
The network’s physicians, nurse practitioners, physician assistant and medical assistants keep doing clinical work. The monitoring, outreach and paperwork belong to CoachCare.
Monitoring, outreach and documentation over 24 months, on CoachCare’s payroll.
Hired, trained and managed by CoachCare. AFCN would otherwise need to recruit and keep them.
The enrollment specialist working in the clinics and the device logistics are CoachCare’s expense.
Direct integration with the eClinicalWorks system AFCN already runs, using its built-in workflows. 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 overviewLittle Rock Family Practice already has care coordinators, a dietitian and a pharmacist, and the network’s clinicians already run transitional care. CoachCare adds daily readings and the staff to watch them, and each of those people keeps the work they do today.
Little Rock Family Practice’s care coordinators follow patients after hospital stays and emergency visits. Daily readings show them which heart failure and kidney patients are slipping between those calls. They keep the relationship; CoachCare adds the readings and the monthly outreach.
The registered dietitian and the pharmacist who manages warfarin, diabetes medications and inhalers see a patient’s home weight and blood pressure in the chart, so a talk about salt, fluid or a diuretic starts from real readings.
Twelve of the network’s clinicians billed transitional care for about 500 traditional-Medicare patients in CY2024. Remote monitoring picks up where that visit ends, so a heart failure patient is still being watched on day 31.
AFCN’s clinicians belong to a two-sided Shared Savings Program ACO. Patients are assigned to it by where they get most of their primary care, so most of the network’s traditional-Medicare patients sit inside its benchmark. Every remote monitoring claim for one of those patients is Part B spending the ACO is measured on. That spending holds up where it prevents admissions worth more than it costs. In this panel that means heart failure and kidney disease, the patients this service line enrolls: about a quarter of AFCN’s Medicare patients.
The same remote monitoring claim lands in two different places depending on how the patient is covered. Medicare Advantage claims are practice revenue and nothing else. Traditional-Medicare claims for an assigned patient are practice revenue that also counts against the ACO’s spending target. Remote monitoring is not one of the primary-care services covered by the ACO’s monthly primary-care payment, so it is billed and paid claim by claim for every Medicare patient, assigned or not. In Pulaski and Saline counties a little under half of the panel is on Medicare Advantage.
Medicare’s share of a year of remote monitoring is about $882 per patient. One avoided hospital stay is worth about $14,703, the ACO’s own average for an acute admission. Whether the program pays its way depends on how often the patient would have been admitted.
| Assigned traditional-Medicare patients | Patients | Admissions per 100 a year | Avoided per 100 at a 30% reduction | Net to the ACO per patient-year | Reduction needed to break even |
|---|---|---|---|---|---|
| Heart failure | 880 | 40 | 12 | +$883 | 15% |
| Chronic kidney disease, without heart failure | 950 | 44.5 | 13.4 | +$1,081 | 13% |
Heart failure and kidney disease patients among the network’s estimated assigned panel. Prevalence from CMS CY2024 claims for the network’s adult primary care clinicians; admission rates from the USRDS 2025 Annual Data Report (kidney disease, 44.5 per 100 at stage 3; 19.5 per 100 without it) and a conservative 40 per 100 for heart failure. The 30% reduction is close to the 29% cut in heart failure hospitalizations that pooled telemonitoring trials report.
At month 24 the forecast has 994 patients on remote monitoring, every one with heart failure or kidney disease. About 460 of them are assigned to the ACO. Choose the reduction in admissions to see where the ledger holds.
The service line enrolls the same patients whether Medicare pays through Part B or a Medicare Advantage plan. These are the patients most likely to be admitted, where a prevented stay is worth more than the program costs.
Daily weight and blood pressure for about 460 assigned patients at month 24. The program pays back to the ACO at a 15% reduction in heart failure admissions and 13% in kidney disease. Little Rock Family Practice’s care coordinators and the clinics’ transitional-care visits carry on as they do today.
The same patients and the same daily readings. Every claim is practice revenue, and none of it touches the ACO’s benchmark. About 460 on remote monitoring at month 24.
In a two-sided ACO the quality score does two jobs. Meeting CMS’s standard keeps the ACO at the full 75% sharing rate. It also holds the share of any loss at the 40% floor, where a miss can push it as high as 75%. The ACO scored 80.3 in PY2024, the year AFCN joined it, against a PY2026 standard of 73.85. Three of the measures behind that score move with what happens to heart failure and kidney patients between visits.
| Measure | PY2024 | Better than | How the program moves it |
|---|---|---|---|
| Q236 Controlling high blood pressure | 81.2 | 56% of ACOs | Home readings on 16 or more days a month and titration between visits. CMS counts readings from a device that transmits them to the clinician. |
| Q484 Admissions for patients with multiple chronic conditions (per 100 patient-years, lower is better) | 43.2 | 14% of ACOs | The measure with the most room. Heart failure and kidney disease drive it, and daily weight and blood pressure, with a call on any confirmed trend, are how a program brings it down. |
| Q479 Hospital-wide 30-day readmission (lower is better) | 15.9% | 22% of ACOs | The clinic’s own transitional-care call, then devices home before the follow-up visit and readings from day two. |
CMS Shared Savings Program Financial and Quality Results, PY2024; each rank is against the ACOs scored on that measure in PY2024.
About 46% of Medicare beneficiaries in Pulaski and Saline counties are on Medicare Advantage, and their plans are rated on a parallel set of measures. For a heart failure or kidney patient on a plan, the monthly program does the same work for the plan’s Star Rating that it does for the ACO’s quality score.
| Star Ratings measure | Weight | How the program moves it |
|---|---|---|
| Controlling blood pressure | Triple | Home readings sent from a cellular cuff count toward the measure, so a controlled month at home closes the gap without waiting for an office reading. |
| Plan all-cause readmissions | Triple | The same post-discharge cadence as Q479: the clinic’s call within two business days, daily weight and BP from day two, and a visit inside the transitional-care window. |
| Medication adherence, blood pressure drugs | Triple | Missed doses show up in the home readings, and the monthly call reviews refills before the patient runs out. |
| Transitions of care | Single | Patient engagement after discharge: the welcome call and first readings, documented in eClinicalWorks beside the clinic’s own follow-up visit. |
CMS Medicare Part C and D Star Ratings, 2026 measure set and weights. Medicare Advantage penetration from CMS State/County Penetration, October 2026.
ACCESS is a ten-year CMS model, launched in July 2026, for technology-supported chronic care that is measured by results: blood pressure, A1c, cholesterol, weight and kidney labs. An approved ACCESS organization enrolls the patient and delivers the care between visits. AFCN’s clinicians stay the patient’s doctors and bill Medicare for reviewing their progress. For a network inside an ACO, it covers the traditional-Medicare patients the last two chapters leave out: those without heart failure or kidney disease.
| Remote monitoring (fee-for-service) | ACCESS (CMS model) | |
|---|---|---|
| What the practice bills | RPM codes each month, under the network’s NPIs | Co-management codes for each review of a care update |
| How patients join | An office visit and a clinician’s order | Patient consent; no referral or order needed |
| Patient cost | 20% coinsurance each month | $0 |
| What is measured | Days of readings and minutes of care | BP, A1c, LDL, weight and kidney labs, against targets |
| Effect on the ACO | Every claim counts as spending from the first month | Outcome payments expected to have no effect on benchmark and spending calculations in 2026 and 2027; counted from 2028 |
| Coverage | Traditional Medicare and Medicare Advantage | Traditional Medicare only, for now |
About 6,000 of the network’s roughly 8,100 traditional-Medicare patients have neither heart failure nor kidney disease. Their conditions are the ones ACCESS pays to improve, and each maps to a track.
Share of traditional-Medicare patients with hypertension; 73% or more have high cholesterol. Scored on blood pressure, LDL and weight.
Share with diabetes; 29% have ischemic heart disease. Scored on A1c, blood pressure and LDL. Stage 3 kidney disease also qualifies, but under this plan those patients are on remote monitoring.
Share with arthritis, the largest source of chronic joint pain on the panel. Scored on patient-reported pain and function.
Share with depression. A second track for the same patient, scored on PHQ-9 and GAD-7, with its own co-management payments to the practice.
CMS CY2024 claims for the network’s adult primary care clinicians, share of traditional-Medicare patients with each condition. Conditions overlap, and CMS caps published prevalence at 75%, so hypertension and high cholesterol are floors.
Medicare pays the practice $30 for each review of an ACCESS care update, up to three a year, plus $10 once at onboarding, per patient per track. The review takes at least five minutes and one care-coordination step, such as a medication change or an updated problem list. There is no patient cost-sharing on these codes.
Six reasons this partnership fits AFCN specifically, not remote care in general.
Annual wellness visits, transitional care after hospital stays, and Little Rock Family Practice’s care coordinators, dietitian and pharmacist are already part of the week. CoachCare adds daily readings for heart failure and kidney patients, and the staff to watch them, beside the people already doing the work.
Built on eClinicalWorks’ own workflows. Readings, documentation and claims live in the chart, and enrollment status is visible at all seven clinics.
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, with no capital outlay.
AFCN’s clinicians set the protocols, sign the care plans and make every clinical decision. Claims go out under the network’s own billing entity and NPIs.
The network’s traditional-Medicare patients average 74. Cellular devices need no home internet, smartphone or pairing, and outreach runs by phone, so no patient has to learn an app.
A 29.1 mmHg drop in Stage 2 hypertension across 2,738 patients at Cardiac Solutions in West Phoenix (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 AFCN’s physician leadership and practice operations team to confirm the Medicare chart count by payer, map how CoachCare’s daily monitoring sits beside Little Rock Family Practice’s care coordinators, dietitian and pharmacist, scope the eClinicalWorks integration, and set the order the seven primary care clinics go live before the first patient enrolls.
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