Working with Providers to Manage Chronic and Transitional Care

Our advocates can monitor, manage, and provide RPM, CCM, and TCM care and documentation for your entire patient population.

An experienced approach to managing chronic disease and improving outcomes by reducing risk and advocating for patient health  

The majority of care for chronic conditions is self-managed at home. HealthBridge identifies clinical risk and social determinants of health for patients in their homes. 

  • We onboard and remotely monitor your patients in accordance with RPM, CCM, and TCM documentation requirements. 
  • We work to mitigate risks and develop patient engagement with your plan of care
  • Our strategy employs a robust initial evaluation by multiple providers, followed by regular and continuous contact with patients via phone, in-home visits, RPM, and telemedicine.
  • We use proprietary predictive tools and technology to identify declining health status, allowing early intervention and avoiding the need for emergency visits and hospitalizations.

Our Approach:

Chronic care management is about what goes on in the home, outside the purview of the traditional medical establishment. 

What if we could identify and mitigate risk at home with effective interventions, defined as the appropriate response at the right time?

We would be enhancing physicians’ care plans by helping patients manage the “last mile” to well-being.  Patients would lead more stable, healthier lives. Healthcare system resources would be utilized appropriately, and costs would be reduced for both patient and payor.

HealthBridge is leading the transition to the next BIG shift in healthcare through a change in the care management of patients with one or more chronic diseases in the home.  Improving care and reducing costs requires a solution that is effective, efficient, and centers on the patient’s home.  To be successful, an organization must deliver the right resources to the right patients at the right time.  This is where HealthBridge excels through the appropriate balance of care provided by our patient support team, our technology platform, and our advocacy.

HealthBridge manages the RPM, CCM, and TCM activities and documentation requirements.  Our devices, team, software, and processes significantly extend visibility and care into the home for patients with complex conditions. By managing patients between their physician visits, we provide vital and consistent “last mile” management of their conditions.  We identify high-risk patient situations through predictive methods and proactively drive appropriate care. This oversight improves the patients’ lives and decreases their use of costly acute care settings. 

We discovered serious care related issues in the home:


Had Serious Medication Issues


Rely on Faulty Home Health Equipment


Have Homes with Significant Fall Risks


Have Financial Considerations that Compromise their Care

Identifying and managing these risk elements is crucial to patient well-being, yet in standard practice, they are left up to the patient and/or caregiver to handle.  Self-managing their condition without sufficient support and knowledge is a key driver of unnecessary resource use.

Program Pillars:


Identifying the clinical and social determinants of health (SDOH) risks impacting a patient and creating a Baseline Risk Index (BRI) for each patient.


Helping patients comprehend their risk issues and getting engaged in their disease management by building trust with our team and creating personal accountability.


Helping patients understand their physicians’ Plan of Care (POC).  It is proven that patients who are engaged and understand their POC exhibit greater compliance.


Using RPM, proactive and consistent tracking of clinical and SDOH data related to a patient’s BRI to drive timely and appropriate interventions.


More than anything, patients need help navigating the resources they need to mitigate some or all their identified risks. HealthBridge IS their advocate.

The foundation connecting these attributes is our proprietary BRIDGE software platform.  This software platform provides a scalable infrastructure that helps identify the risk profile of each patient, initiate alerts for the team, and track mitigating activities.  It also tracks population metrics that help us keep the program aligned with payor key objectives.

Our Patient Support Team

Care Advocates

Engage in periodic and ad hoc communication with patients.  Key drivers for patient engagement and advocacy. They escalate critical issues to Field Clinicians and MDs for further review.

Field Clinicians

Non-MD clinical team members whose predominant focus is patients in their home. Conduct initial home assessment along with periodic updates. Actively mitigate risk and escalate concerns to MDs.



Oversight of high-risk and urgent need patients. Last line of defense in preventing unwarranted ED visits and hospitalizations. Advocate for patients with direct communication to their PCP’s and Specialists.

By sending clinicians into the home, our team identifies multiple risk elements through a comprehensive assessment of the patient.  These risk elements, which could lead to future hospitalizations and/or ED visits, might include:

  • Clinical elements (medication reconciliation, O2 dependent, other)
  • Mental/emotional issues (substance abuse, depression/anxiety, other)
  • Socioeconomic factors (financial, transportation, other) 
  • Home environment conditions (caregivers, fall risk, other)

Genuine and Compassionate

Practical, passionate, and optimistic, our care advocates and clinicians are dedicated to helping others. Our culture is warm and inviting. We partner with patients and their doctors to find the best solution for their needs.

Knowledgeable and Experienced

Our model was born out of our experience with a successful respiratory equipment and services company. We’ve evolved our program to manage multiple chronic conditions and have worked with numerous patients, physicians, support associations, and clinics throughout our targeted coverage area.

Reliable and Responsive

It is our goal to maintain our patient’s well-being and stability so they can live better lives. We achieve this through regular contact so that we can deliver the right resources at the right time.

HealthBridge partners with patients, their families, and other care providers to coordinate complex, high-quality care. We take a holistic approach to provide patients with tailored care that helps them manage their chronic conditions better.

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