Care management

The team that stays involved between the visits.

Daily check-ins, monthly clinical review, remote monitoring, and the social-determinants navigation that clinical care alone cannot reach. The longitudinal layer that holds the rest of RBYS together.

Call 800.494.1238 See a month on the panel

Enrollment Post-discharge or referralPlan attribution available

Cadence Daily · Weekly · MonthlyPer care plan

Pathways CCM · RPM · BHI · TCMMedicare and MA aligned

Coverage Greater OrlandoOrange · Seminole · Osceola · Lake

WHAT IT IS · 01 +

Care management is the longitudinal layer.

Transportation gets the patient home. The in-home visit catches the medication confusion. Care management is what happens between those moments and stays in place for as long as the member is on the panel. It is the part of RBYS that does not stop.

What it is

A care plan that gets updated, not filed away.
The same care manager every month, not a rotating queue.
Daily RPM transmissions reviewed by a real clinician.
The coordinating call to the PCP, specialist, or pharmacy.
The social-determinants work: housing, food, benefits, transportation.
The escalation pathway when something changes between visits.

What it isn't

A monthly auto-generated call from a vendor the patient has never met.
A portal message they ignore.
A replacement for the PCP or specialist relationship.
A one-time intake that ends after enrollment.
Generic disease management content emailed to the patient.
A call center reading from a script.

A MONTH ON THE PANEL · 02 +

What a typical month actually looks like.

For a member enrolled in care management with RPM and CCM, the month follows a defined cadence. Daily monitoring, weekly check-ins, monthly review, and an escalation pathway any time something changes.

Daily

RPM transmissions reviewed.

Members on remote monitoring transmit vitals daily from connected devices. An RN reviews the data, flags outliers, and follows up with the member when readings move outside the agreed-upon thresholds.

WhoRN, supported by RPM platform

Weekly

Care manager check-in call.

A scheduled call from the same care manager every week. Catches changes in symptoms, medication compliance, family situation, and any access barriers (transportation to appointments, refills, durable medical equipment).

WhoCare manager

Monthly

Clinical care plan review.

The PA or NP reviews the full care plan with the RN and care manager. Adjustments to the plan, medication changes, referrals to the PCP or specialist, and updates documented and sent back to the partner.

WhoPA or NP + RN + care manager

As needed

In-home touchpoint.

When a phone call is not enough, an EMT is dispatched to the home for a hybrid visit with the clinician on video. Used for medication reconciliation after a change, post-fall checks, and any situation that needs a person in the room.

WhoEMT + clinician on video

Continuous

SDOH navigation.

The social worker addresses the social determinants that drive total cost of care. Food access, housing stability, benefit enrollment, transportation to non-RBYS appointments, and connection to community-based organizations in Greater Orlando.

WhoSocial worker

Escalation

The call to the PCP, specialist, or 911.

When something changes between visits, the care team escalates. To the PCP for medication adjustment. To the specialist for a flare. To the case manager at the partner. To 911 if it is acute. Documented and tracked through the same system.

WhoCare manager or RN, escalating

THE CARE TEAM · 03 +

Five roles, one team.

Care management at RBYS is not a single phone call from a generic case worker. It is a defined team with separate responsibilities, working from the same care plan and the same record.

Role 01

Care manager

The relationship anchor. Same care manager every month for every member. Knows the patient, the family, the home situation, and the history. Owns the care plan and the weekly check-in cadence.

Plan owner · Weekly contact

Role 02

Registered nurse

Clinical eyes on the panel. Reviews RPM transmissions daily. Catches outliers. Triages escalations. Conducts the monthly chronic care management touchpoint. Coordinates with the clinician when something needs a clinical decision.

Clinical review · Daily

Role 03

EMT

The physical presence when a phone call is not enough. Dispatched to the home for unplanned touchpoints, medication reconciliations after a change, and the post-discharge 48-hour visit when the member is enrolled in our in-home care service.

In-home touchpoint · As needed

Role 04

PA or NP

The clinical decision-maker. Joins in-home visits by video. Reviews and signs off on the monthly care plan. Authorizes medication changes within scope, refers to the PCP or specialist when out of scope. Documents the visit note.

Clinical authority · Monthly

Role 05

Social worker

The social-determinants navigator. Handles benefit enrollment, food access, housing stability, transportation to non-RBYS appointments, and the connection to community-based organizations across Greater Orlando.

SDOH navigation · Continuous

Role 06

The whole team

What makes care management work is that the five roles above operate from the same record, the same care plan, and the same daily standup. Members talk to different people but never have to repeat themselves.

One record · One plan

Most care management programs feel like a rotating call center. This one feels like a team you already know. Same care manager every month, same RN reviewing the daily transmissions, same EMT walking into the home. Continuity is the program.

BILLING PATHWAYS · 04 +

Aligned to Medicare and MA pathways.

Every care management service maps to an established Medicare or Medicare Advantage billing pathway. The list below is what your plan will see on encounter data.

TCMTransitional Care Management The bridge from hospital discharge to home. Face-to-face visit within 7 or 14 days, medication reconciliation, and care plan documentation. Triggers the start of ongoing care management for the member. CPT99495 · 99496

CCMChronic Care Management The monthly care coordination touchpoint for members with two or more chronic conditions. Non-face-to-face time spent on care plan management, communication with other clinicians, and member outreach. CPT99490 · 99491 · 99437

RPMRemote Patient Monitoring Device setup, daily transmissions, and monthly clinical review of monitored vitals. Used for members managing hypertension, diabetes, heart failure, or other conditions where daily data changes the care plan. CPT99453 · 99454 · 99457 · 99458

BHIBehavioral Health Integration Co-located behavioral health support for members with depression, anxiety, or substance use diagnoses. Integrated into the same care plan and team as the medical management, not referred out as a separate service. CPT99492 · 99493 · 99494

WHEN WE ENROLL · 05 +

Care management is not for every patient.

Enrollment is triggered by specific events or attributions. Most members enter care management through one of the four paths below.

Post-discharge from hospital or SNF

The most common path. A hospital case manager or SNF discharge planner refers the member alongside transportation home and the 48-hour in-home visit. Care management begins the day the member leaves.

PCP referral

A primary care physician identifies a high-risk patient who would benefit from longitudinal coordination outside the clinic. The PCP refers the member to RBYS and stays the clinical home; we extend the reach.

Plan attribution for high-risk members

Medicare Advantage, D-SNP, and Managed Medicaid plans attribute members to RBYS based on risk stratification, utilization data, or chronic condition prevalence. The plan triggers the enrollment; we run the program.

Family request

A family member calls asking about ongoing support for a parent or spouse. We confirm eligibility through the patient's plan or PCP, and the enrollment moves forward through the right partner pathway.

HOW TO ENROLL · 06 +

Three paths to start care management.

At this stage, most enrollments come through partnerships with hospitals, health plans, and primary care practices. The path matters less than the destination.

01 / Hospital or SNF

Through the case manager.

Hospital and SNF case managers refer the member as part of the discharge plan. Care management begins alongside transportation home and the 48-hour in-home visit.

Most common path

02 / Health plan

Through plan attribution.

Medicare Advantage, D-SNP, and Managed Medicaid plans contract with RBYS to deliver care management for attributed high-risk members. Plan triggers the enrollment; we run the program against the agreed-upon cadence.

Plan-coordinated

03 / PCP referral

Through the primary care doctor.

A primary care physician refers a high-risk patient who would benefit from longitudinal coordination outside the clinic. The PCP stays the clinical home; we extend the reach into the home and between visits.

Clinical-coordinated