Chronic Care Management and Remote Patient Monitoring at MFM Health
Ongoing Support for Managing Chronic Conditions
Your health matters between visits, too. MFM Health offers Chronic Care Management and Remote Patient Monitoring services to support eligible patients managing ongoing conditions such as diabetes, hypertension, heart disease, COPD, and other chronic health concerns.
The program may include one or more of the following services, depending on individual care needs:
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Advanced Primary Care Management (APCM)
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Chronic Care Management (CCM)
These services are designed to enhance communication, help monitor ongoing health concerns, and promote consistency in care between visits.
Program Overview
Chronic Care Management and Remote Patient Monitoring provide regular outreach and care coordination outside of standard office visits. These services may include scheduled phone check-ins, care plan support, medication-related education, coordination with your care team, and, when appropriate, at-home monitoring devices.
What is Advanced Primary Care Management (APCM)?
APCM supports patients living with two or more chronic conditions through enhanced coordination and regular follow-up between visits.
This program may include:
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A structured care plan tailored to ongoing health needs
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Communication between healthcare settings and specialists
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Education and monitoring related to chronic conditions and medication use
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The goal of APCM is to promote consistency in care, encourage proactive engagement, and support long-term health management.
What is Chronic Care Management (CCM)?
CCM provides ongoing coordination and follow-up for patients managing chronic health conditions between office visits.
Services may include:
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A structured care plan developed in collaboration with your provider
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Flexible scheduling options, including telehealth appointments and extended office hours
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Outreach from the care management team for routine check-ins and monitoring
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Coordination across healthcare settings, including transitions from hospital to outpatient care
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Education and resources to support medication use, healthy habits, and self-care strategies
What is Remote Patient Monitoring (RPM)?
RPM uses connected health devices to securely share key health data with your care team between visits. Devices may include:
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Blood pressure monitors
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Glucose monitors
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Weight scales
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Pulse oximeters
Data from these devices is reviewed with support from our care management partner, Medsien, and shared with your MFM Health care team when follow-up may be needed.
RPM supports ongoing communication and helps track trends in your health over time, allowing your care team to stay informed between appointments.
Note: RPM may be recommended based on your health needs. Coverage and costs vary by insurance; our team can provide additional information before enrollment.
Continuous Support
A dedicated care coordinator maintains regular communication with you between visits to review updates, monitor ongoing needs, and help coordinate next steps in your care plan.
Coordinated Care
Your care team works collaboratively with your primary care provider and specialists to support communication, continuity, and alignment across all aspects of your health.
Ongoing Monitoring
Regular communication and data review help your care team stay informed about changes in your health between visits, allowing for timely follow-up when needed.
Convenience
Receive care coordination and support between visits through scheduled phone or virtual check-ins, reducing the need for additional office appointments.
Benefits of Chronic Care Management at MFM Health
How do I know if I’m eligible?
Patients who have two or more chronic health conditions expected to last 12 months or longer may qualify for Chronic Care Management. Remote Patient Monitoring may also be recommended based on your health needs.
You may be contacted by MFM Health or Medsien with information about enrollment, or your provider may review the program with you during an appointment. You can also ask your care team whether these services are appropriate for you.
Our partnership with Medsien
MFM Health has partnered with Medsien to help provide Chronic Care Management and Remote Patient Monitoring services. If you are a Medicare beneficiary and qualify, a certified medical assistant may contact you to see whether you are interested in enrolling. You may also call 978-778-2653 to learn more. Participation is voluntary, and you may stop participating at any time.