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Featured PartnerService ProviderTechnology / SoftwareOsleri Ambient Value-Based Care Management
Osleri
www.osleri.comAI-native care management for rural health systems Osleri is an AI-enabled care management platform that keeps rural patients supported between visits — and turns that care into sustainable revenue for the systems that…
Company Overview
AI-native care management for rural health systems
Osleri is an AI-enabled care management platform that keeps rural patients supported between visits — and turns that care into sustainable revenue for the systems that serve them. From the day a patient leaves the hospital through years of chronic disease management, Osleri closes the gaps where rural outcomes are usually lost.
The Problem
Rural health systems are running on the thinnest margins in American medicine, and the pressure is only intensifying. Every dollar of earned revenue matters — and too much of it is walking out the door in the space between visits.
RHTP Capabilities
Primary focus
Remote Monitoring & Care-at-HomeAI, Analytics & ReportingChronic Disease & Preventive Care
Service areas
Behavioral Health & Substance UseCare Coordination & NavigationCommunity Health & EngagementPrimary Care & AccessTelehealth & Virtual CareRemote Monitoring & Care-at-HomeMobile Health & EMSHealth IT, EHR & InteroperabilityAI, Analytics & ReportingWorkforce Training & RecruitmentChronic Disease & Preventive CareMaternal, Youth & School-Based CareAging, Dementia & Long-Term CareFinancial Sustainability & Revenue CycleSocial Drivers, Food & Housing Support
RHTP priority alignment
Sustainable AccessWorkforce DevelopmentCommunity Health and PreventionTechnology ModernizationInnovative Care ModelsBehavioral HealthMaternal HealthChronic Disease PreventionData ModernizationRural Infrastructure
Care settings
Primary Care ClinicRural Health ClinicFQHCHome HealthCritical Access HospitalCommunity Health CenterPublic Health DepartmentSkilled Nursing FacilityBehavioral Health ClinicRural Hospital
Problems addressed
Limited access to primary careLimited access to specialistsWorkforce shortageBehavioral health shortageChronic disease management gapMaternal care gapCare coordination gapHospital readmission riskPoor patient engagementLow health literacyLack of broadband / rural connectivityLack of EHR / interoperabilityLack of reporting capacityRevenue leakageOtherLong travel distanceTransportation barrierGrant implementation burdenCommunity outreach gap
Use Cases
1Scenario
Post-discharge transitions (TCM): Automated follow-up, medication reconciliation, and care-plan activation in the days after discharge — cutting readmissions and capturing TCM revenue.
2Scenario
Ongoing chronic & primary care management (APCM/CCM): Structured monthly touchpoints that keep chronic and complex patients managed between visits, billed through the right CMS program per patient.
3Scenario
Remote therapeutic monitoring (RTM): Multi-specialty between-visit monitoring with AI-generated notes, surfacing high-risk patients early and generating net-new reimbursement.
The Solution
Software PlatformSaaSClinical ServiceTelehealth ServiceRCM / Billing ServiceImplementation SupportData / Analytics ServiceStaffing Service
How it works
Osleri is an end-to-end, AI-native value-based care platform that helps rural clinics, critical access hospitals, and FQHCs deliver continuous, reimbursable care between patient visits. We automate Remote Therapeutic Monitoring (RTM), Advanced Primary Care Management (APCM), Chronic Care Management (CCM), and Transitional Care Management (TCM) through a single workflow that works alongside existing EHR systems via HL7/FHIR interoperability — no expensive integration, no additional downloads, no new software to learn, and no added clinical staff required.
Standard package includes
1. Remote Therapeutic Monitoring (RTM)
Multi-specialty monitoring (cardiology, musculoskeletal, respiratory, pain management) that catches high-risk patients between visits before they become readmissions — with automated clinical notes and full CMS billing support (CPT 98975–98981, plus the new 2026 codes 98985 and 98979 that make short-episode and post-discharge patients billable for the first time).
2. Advanced Primary Care Management (APCM)
Optional add-ons
Optional Add-Ons: Flexible, affordably priced services for practices that want Osleri to take more off their plate while generating meaningful outcomes, revenue and cost-savings.
Rural relevance
Rural health transformation is fundamentally about doing more with less — extending care to more patients, across greater distances, with fewer providers and thinner margins. But transformation only happens if rural providers stay open long enough to deliver it. Osleri is built to do both: keep the lights on financially while optimizing care delivery and population health between visits.
Implementation
Timeline
Less than 30 days
Training
Yes
Ongoing Support
Yes
Grant Reporting
Yes
Site requirements
EHR accessData sharing agreementHIPAA BAAIT support
Detailed rollout plan
Osleri is designed for fast, low-friction deployment in resource-constrained rural environments. Our implementation process is built around one principle: minimize burden on clinical staff while maximizing time-to-value.
Phase 1 — Setup & Integration (Weeks 1–2)
Reporting metrics supported
Patient & Enrollment: Total enrolled patients, enrollment by program (CCM, RTM, TCM), eligible vs. enrolled rate, new enrollments per period, patient demographics, payer mix
Clinical Engagement: Monthly care touchpoints completed, patient response and engagement rates, missed or overdue outreach, high-risk patient flags and escalations, care plan completion rates
Who It's For
Ideal customers
Rural HospitalCritical Access HospitalFQHCRural Health ClinicCommunity Health CenterBehavioral Health ProviderSenior CenterCorrectional Health ProgramHome Health AgencyNonprofit / CBOPayer / Medicaid PlanTribal Health OrganizationSchool-based Health CenterLocal Health DepartmentState Agency
Multi-site deployment
Statewide programs
Rural / frontier
Technical & Compliance
Involves PHI
Signs HIPAA BAA
Compliance documentation available
HIPAA statementSOC 2Data sharing agreement templateBAA templatePrivacy policy
EHR / system integrations
We are EMR agnostic and have experience interoperating with Epic, Cerner, eClinicalWorks, Athena Health and more
Credentials & Evidence
Critical Access HospitalsFQHCsRural Health ClinicsMedicaid populationsMedicare populationsCMS programsCorrectional healthHome-based careTribal healthHRSA programsState agencies
Expected outcomes / measurable benefits
Osleri's impact is grounded in published evidence on the CMS care-management programs it operationalizes (CCM, TCM) and the broader remote-monitoring literature. Because Osleri automates the same structured touchpoints these studies evaluated — post-discharge follow-up, monthly chronic care management, and between-visit monitoring — these findings represent the outcome ranges rural deployments can target, measured against each site's own baseline.
Published outcomes / metrics
Imported from table-style PDF extraction; needs manual verification.
Rural health experience detail
Osleri has built its platform and operational model from the ground up in rural and underserved care settings. Our partnerships, pilots, and deployments are concentrated in markets where the care continuity gap is most acute — rural Texas, community health networks, and safety-net systems serving high proportions of Medicaid and uninsured patients.