A scalable, profitable remote care service line for ODA: remote monitoring, chronic care management and advanced primary care management for the Medicare patients your health center already serves, billed under ODA’s own NPIs on top of the PPS encounter and run by a CoachCare care team inside eClinicalWorks
Medicare is changing what it pays health centers 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 health center where most Medicare patients also qualify for Medicaid and carry hypertension and diabetes together, those weeks decide how the year goes.
ODA has served Williamsburg since 1974, when it opened as one primary care and dental facility. Today it runs ten Brooklyn sites and two summer sites in the Catskills, with urgent care at its main Wallabout Street center until midnight every day of the year. It served 90,063 patients in 2025, 5,858 of them on Medicare, and 59% of those Medicare patients also qualify for Medicaid. Cardiology, endocrinology, nutrition and social work sit in the same buildings as primary care.
A Medicare panel that has grown every year since 2022, in which most patients also qualify for Medicaid, and a health center that already ranks in HRSA’s best quartile on diabetes control, with room to climb on the measures remote care moves.
ODA has added more than ten points of blood-pressure control in four years and sits in HRSA’s third quartile. Across 4,690 hypertensive patients the next points come from home readings and medication changes between visits, which is where a single office reading misses most.
Poor A1c control is already lower than at three in four health centers. Across 2,991 patients with diabetes, 548 were still above 9% or untested in 2025, and most of them carry hypertension too. Home glucose and a monthly care-management call, with ODA’s own endocrinologist in the building, reach them between lab draws.
Statin therapy for patients at cardiovascular risk (66.5%) and depression screening (61.2%) are the two measures with the most room in 2025. Both are monthly-call work: a statin started or restarted, a PHQ screen done by phone and routed to ODA social work the same week.
Each step below added sites, services or patients. 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 ODA touches a patient at one moment: a medical visit, an urgent-care visit at night, a specialist referral, a pharmacy pickup, 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 health center to see what changes.
ODA’s physicians, nurse practitioners and physician assistants set the protocols and own every clinical decision. CoachCare staffs and runs the program. Everything runs through the eClinicalWorks system ODA already uses, 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 ODA reports to HRSA every year. Patients with uncontrolled hypertension, diabetes or several chronic conditions are flagged using criteria ODA’s clinicians set, so the right patients surface at a visit, at an annual wellness visit, or on an outreach list.
Example criteria. ODA’s clinicians set and own the flag logic for each condition.
Patients enter at a medical visit, at their annual wellness visit, or after a hospital stay. Either way they land in the same monthly loop: office visits, care management and physiologic monitoring, each one informing the next.
BP 162/96 on three agents and an A1c above 9. The clinician places the remote care order during the visit, or at the annual wellness visit.
Cellular cuff and glucometer at home, a welcome call, and how to take a reading that counts.
99453Home averages drive medication changes month to month; the care-management call covers the other conditions.
99454 · 99457 · 99490 or G0557Office visits ↻ care management ↻ physiologic monitoring.
Flagged in eClinicalWorks when the discharge notice arrives. Devices ordered to the home.
Contact within two business days, medication reconciliation, an ODA visit in 7–14 days.
TCM 99495 · 99496Readings start right away. The short-month device code covers the first partial month.
99453 · 99445 · 99490Office visits ↻ care management ↻ physiologic monitoring.
The clinician orders from the chart, or a CoachCare enrollment specialist working at an ODA site enrolls the patient during the visit.
Cellular devices arrive ready to use. No Wi-Fi, no smartphone and no home internet needed, and nothing for the patient to pair.
The patient’s assigned care manager walks through the device, the routine, and who to call. The language plan for Yiddish- and Spanish-speaking patients is set with ODA before launch.
Readings reviewed, outreach logged, care plan updated, escalations routed. 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 site.
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 site 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 site. A critical reading on its own goes to the site. This cannot be configured away.
At month end, three things come out of the program: clean claims in eClinicalWorks, an operational report for ODA’s leadership, and a clinical outcomes report that lines up with the measures ODA reports to HRSA.
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 health center. Sample below at the modeled month-12 census.
A 24-month forecast for an ODA remote care service line: remote monitoring, chronic care management and advanced primary care management across the Medicare panel, priced at the CY2026 national rates health centers bill, on top of the PPS encounter, with every patient priced at the Medicare amount. Alongside it, what the program does for patients and for the people who run it.
Four visits a year leave 361 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.
Hypertension is the most common chronic condition among ODA’s adult patients and the one 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 practice with three offices, put 2,738 patients on CoachCare RPM with home blood-pressure monitoring.
ODA reports clinical quality to HRSA every year, and most of the measures it is ranked on depend on work this program does every month. Select a measure to see how.
Monitoring the panel every day tells the health center who needs to be seen now, which the schedule alone cannot. Patients surface from their home data before they come in sicker.
When an ODA patient goes home from the hospital, the next 30 days decide whether they come back. Transitional care management pays for that month; remote monitoring and care management carry the patient past it.
Flagged in eClinicalWorks for post-discharge monitoring.
A call within two business days and medication reconciliation.
Readings start right away. 99445 bills the short first month.
Monthly RPM with CCM or APCM while it adds value.
Daily weight and BP from day two, three touches inside two weeks, a visit with ODA’s cardiologist when the trend returns.
Oxygen saturation and symptoms after an exacerbation, with a quick visit before a return trip to the emergency department.
Glucose and BP while medications change after a stay, and a fluid check for patients with CKD.
Patients who carry hypertension or diabetes into a behavioral health admission stay on their readings and their monthly call until the follow-up visit.
Every code the service line can bill, at the CY2026 national Medicare rates health centers bill. Since January 1, 2026, a health center bills each of these on its own, in addition to the PPS encounter for the visit. Build a patient-month to see what one patient is worth.
CY2026 Medicare Physician Fee Schedule, national non-facility amounts: the rate a federally qualified health center bills for these codes at every site, in addition to the PPS encounter. New York Medicaid pays remote monitoring only to health centers that bill under APGs; ODA’s Medicaid visits are paid under PPS, so the forecast counts Medicare only. Only one device code (99454 or 99445), one first-tier management code (99457 or 99470) and one care-management program (CCM or APCM) bill per patient per month. About 58% of Medicare beneficiaries in Kings County are in Medicare Advantage. Those plans must pay at no less than the Medicare rate, a floor; individual contracts set their own terms for the care-management code families, and the forecast prices every patient at the Medicare amount.
ODA can start with remote monitoring and keep care management with its own department, or run all three programs through CoachCare. Either way the program is net-positive. Select a deployment to redraw the charts.
| Full service line | Year 1 | Year 2 | 24 months |
|---|---|---|---|
| Net reimbursement | $1,062,607 | $2,535,053 | $3,597,660 |
| CoachCare cost (program and eClinicalWorks fees) | $625,520 | $1,443,974 | $2,069,494 |
| Net to ODA after fees | $437,087 | $1,091,079 | $1,528,166 |
| Margin to ODA | 41.1% | 43.0% | 42.5% |
| By program: remote monitoring $1,467,446 · chronic care management $1,269,537 · advanced primary care management $860,677 in net reimbursement. The remote-monitoring deployment alone runs at a 42.4% margin. Month 1 runs −$4,381 while implementation and the eClinicalWorks setup post against a census still ramping; net-positive from month 2. Medicare fee-for-service reimbursement only, in addition to the PPS encounter; no Medicaid or grant dollars are in these figures. | |||
Change the assumptions and the 24-month forecast recalculates. Start from a deployment or move the sliders yourself. ODA’s own Medicare chart count by payer, and the number of clinicians referring, are the first things 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.
ODA’s physicians, nurse practitioners, physician assistants and nurses keep doing clinical work. The monitoring, outreach and paperwork belong to CoachCare, at a time when every health center is competing for the same nurses.
Monitoring, outreach and documentation over 24 months, on CoachCare’s payroll.
Hired, trained and managed by CoachCare. ODA would otherwise need to recruit and keep them.
The enrollment specialist working at ODA sites and device logistics are CoachCare’s expense.
Direct integration with the eClinicalWorks system ODA 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 overviewThe staff, protocols and eClinicalWorks workflow built for remote monitoring and care management can take on the next programs ODA’s patients qualify for, without a second hiring plan.
ODA already places social workers inside primary care. Monthly behavioral health integration fits the same care-manager calls and the same chart, and it is the program built for depression follow-up.
A call within two business days of every discharge and a visit inside two weeks, run on the same escalation engine and billed by ODA.
Medicare now pays for community health workers’ time addressing the social needs that get in the way of treatment. The same care-plan record and monthly cadence carry it.
Six reasons this partnership fits ODA specifically, not remote care in general.
ODA already ranks in HRSA’s best quartile on diabetes control, keeps cardiology, endocrinology, nutrition and social work under the same roof as primary care, and runs its own care management department. Remote monitoring adds daily readings to that work, and CoachCare can take on as much or as little of the care management as ODA wants.
Built on eClinicalWorks’ own workflows. Readings, documentation and claims live in the chart, and enrollment status is visible at every site.
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, and fees are per active patient per month, with no capital outlay.
ODA’s physicians, nurse practitioners and physician assistants set the protocols, sign the care plans and make every clinical decision. Claims go out under ODA’s own billing entity and NPIs, separate from the PPS encounter.
Cellular devices that need no home internet, no smartphone and nothing to pair, and outreach by phone, so no patient has to learn an app. Enrollment, device instructions and outreach are scoped with ODA for Yiddish- and Spanish-speaking patients before the first patient enrolls.
A 29.1 mmHg drop in Stage 2 hypertension across 2,738 patients at Cardiac Solutions (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 ODA’s leadership to confirm the Medicare chart count by payer (traditional Medicare, Medicare Advantage and dual-eligible), walk through how the care management department runs today, settle the language plan for Yiddish- and Spanish-speaking patients, and scope the eClinicalWorks workflow for the four adult-medicine sites.
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