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Featured PartnerserviceCareAtlas — HealthQuilt platform + embedded care navigation
CareAtlas
careatlas.comCareAtlas helps healthcare organizations manage Medicare care coordination programs, including Remote Patient Monitoring (RPM), Chronic Care Management (CCM), Transitional Care Management (TCM), and Advanced Primary…
Company Overview
CareAtlas helps healthcare organizations manage Medicare care coordination programs, including Remote Patient Monitoring (RPM), Chronic Care Management (CCM), Transitional Care Management (TCM), and Advanced Primary Care Management (APCM). We embed licensed care navigators and clinicians—real people, supported by AI—directly into your team. Our staff builds ongoing relationships with your patients, offering regular check-ins and support to help them manage chronic conditions at home.
RHTP Capabilities
Primary focus
Care Coordination & NavigationRemote Monitoring & Care-at-HomeAI, Analytics & Reporting
Service areas
Behavioral Health & Substance UseCare Coordination & NavigationPrimary Care & AccessRemote Monitoring & Care-at-HomeAI, Analytics & ReportingChronic Disease & Preventive CareAging, Dementia & Long-Term CareFinancial Sustainability & Revenue CycleSocial Drivers, Food & Housing Support
RHTP priority alignment
Sustainable AccessWorkforce DevelopmentInnovative Care ModelsBehavioral Health
Care settings
Primary Care ClinicFQHCCritical Access HospitalRural Hospital
Problems addressed
Limited access to primary careLong travel distanceChronic disease management gapCare coordination gapHospital readmission riskLack of broadband / rural connectivityLack of EHR / interoperabilityFood insecurityTransportation barrier
Use Cases
1Scenario
Rural hospital reduces 30-day readmissions: CareAtlas serves as provider of record for post-discharge TCM, RPM, and CCM. In a 145-patient cohort (89% age 65+, 38% COPD, 24% CHF), readmissions ran 14.8% vs. the 19% CMS benchmark, a 23% relative reduction, with no new hires and no upfront investment by the hospital.
2Scenario
Rural practice, RHC, or FQHC launches Medicare care coordination (APCM, CCM, RPM) without adding staff: CareAtlas navigators handle enrollment, monthly outreach, documentation, and billing-ready exports under the practice's NPI, generating new Medicare revenue from the first billable month.
3Scenario
Patients without WiFi or smartphones are monitored at home using cellular, one-button devices shipped directly to them. A named care navigator activates each patient and calls monthly; 73% of enrolled patients submit readings 8+ days per month and fewer than 1% voluntarily drop out.
The Solution
Clinical ServiceSaaSSoftware PlatformRCM / Billing ServiceStaffing ServiceDevice / HardwareImplementation SupportTelehealth Service
How it works
CareAtlas operates Medicare care coordination programs (RPM, CCM, TCM, and APCM) for rural hospitals, clinics, and health centers that don't have the staff to run them well. We embed licensed care navigators, real people supported by AI, into your patient population. Each enrolled patient gets a named navigator who calls monthly, triages daily device readings, and reaches out within 48 hours of discharge.
Standard package includes
Full-service care coordination program: dedicated licensed care navigators, the HealthQuilt coordination platform, cellular RPM devices shipped to patients (device cost absorbed by CareAtlas), patient enrollment and consent workflow, monthly navigator touches, daily RPM triage, 48-hour post-discharge TCM outreach, AI-assisted documentation, EHR write-back of structured clinical summaries, and monthly billing-ready exports. Implementation, training, and ongoing program management included. Typical path to first billable month is about 60 days from signature.
Optional add-ons
24/7 after-hours coverage · team augmentation (overflow navigator capacity behind your existing staff) · platform-only licensing for organizations with their own care management team · provider-of-record arrangement for hospitals (CareAtlas's affiliated professional corporation bills Medicare directly) · grant and quality reporting support.
Rural relevance
Rural organizations face the exact gap these programs were designed to close: high chronic disease burden, long travel distances, and no labor market to hire care managers from. Nursing vacancy rates have climbed 4-5x over the past decade, so "hire navigators" is not a realistic plan for most rural hospitals and clinics. CareAtlas supplies that workforce remotely, with devices that work on cellular networks where broadband doesn't reach, and a revenue model that turns federally supported care coordination codes into a sustainable funding stream rather than a new cost center. The result is between-visit care for rural Medicare patients, fewer avoidable readmissions, and net-new revenue that strengthens the finances of the rural providers delivering it.
Implementation
Timeline
Depends on scope
Training
Yes
Ongoing Support
Yes
Grant Reporting
Yes
Site requirements
Staff timeEHR accessData sharing agreementHIPAA BAAPatient outreach supportAdministrative staffBilling setup
Detailed rollout plan
CareAtlas runs a structured 90-day implementation from agreement signature to a fully operating program, with the first billable month typically reached around day 60.
Weeks 0-1: Kickoff and paperwork. We execute the BAA and data sharing agreement, confirm NPI and billing arrangements (under the provider's NPI, or with CareAtlas's affiliated professional corporation as provider of record for hospital partnerships), and introduce our operations lead to the site's billing contact. The applicant's lift at this stage is administrative: signatures, an NPI letter, and a billing contact.
Reporting metrics supported
Patients enrolled by program (RPM/CCM/TCM/APCM) · device adherence (patients submitting readings 8+ days/month) · navigator touches per patient per month · 48-hour post-discharge contact rate · 30-day readmissions vs. CMS benchmark · voluntary disenrollment rate · billable months and billing-ready export delivery · gross Medicare reimbursement generated · quality-measure (eCQM) reporting support for MIPS/MSSP programs · custom grant-reporting cadences supported.
Who It's For
Ideal customers
Rural HospitalCritical Access HospitalFQHCRural Health ClinicState AgencyPayer / Medicaid PlanTribal Health Organization
Multi-site deployment
Statewide programs
Rural / frontier
Technical & Compliance
Involves PHI
Signs HIPAA BAA
EHR / system integrations
athenahealth (live integration). Standards-based FHIR connectivity (ONC Cures Act §170.315(g)(10)) supports read access and return of structured summaries across major certified EHRs; where direct integration is not yet enabled, we exchange via secure document workflows. No rip-and-replace and no separate physician login required.
Credentials & Evidence
Critical Access HospitalsFQHCsRural Health ClinicsMedicare populationsCMS programsHome-based care
Expected outcomes / measurable benefits
Demonstrated in a recent 145-patient rural cohort (Oct 2025; 89% age 65+, 38% COPD, 24% CHF): 30-day readmissions of 14.8% vs. the 19% CMS benchmark (23% relative reduction); 73% of patients submitting device readings 8+ days/month; under 1% voluntary disenrollment; 4+ navigator touches per patient per month. Program-level benefits we track and report: patients enrolled in chronic care coordination, RPM uptake, post-discharge follow-up within 48 hours, net-new Medicare reimbursement to participating providers ($50-$120 gross per patient per month depending on program mix), and quality-measure reporting. Cohort results are disclosed with population composition; outcomes vary by site and population.
Published outcomes / metrics
October 2025 cohort, 145 patients (89% age 65+, 38% COPD, 24% CHF): 30-day readmission rate of 14.8% vs. the 19% CMS benchmark, a 23% relative reduction; 73% device adherence (readings 8+ days/month); under 1% voluntary discontinuation; 4+ navigator touches per patient per month. Cohort composition disclosed for honest benchmark comparison.
Rural health experience detail
CareAtlas's flagship deployment is a partnership with a rural Texas health system serving a multi-county West Texas area, launched summer 2025. CareAtlas serves as provider of record for post-discharge care coordination: cellular RPM devices shipped to patients' homes (no WiFi required), a named navigator per patient, monthly CCM touches, 48-hour TCM outreach, and structured summaries returned into the partner's EHR. The partnership was recognized in the HIMSS26 Emerge Experience Winner's Circle (Hospital Systems category). Our delivery model is built for rural constraints: no local hiring required, no broadband dependency, and no upfront investment by the hospital.
References available upon request