Mercy Care runs eight clinics, two mobile units, street medicine that works day and night, and 33 medical respite beds. Inside that mission sits a 1,132-patient Medicare panel — 63% of it dual-eligible — whose hypertension and diabetes are decided in the weeks between appointments. Since January 1, 2026, that between-visit work bills code by code at national rates, on top of the PPS encounter. This is the business case for staffing it without hiring anyone.
The headline counts 334 unique patients in active remote care at Month 24. The enrollment chart and the Scenario Explorer show 512 active program enrollments (services): CCM and APCM cannot be billed for the same patient in the same month, so the 136 CCM and 119 APCM enrollments are 255 distinct care-management patients. Most of the 258 RPM enrollments sit inside those cohorts as a second program on the same patient, and the balance are monitoring-only — together, 334 unique patients. Program enrollments are never labeled “patients.”
Mercy Care reports its clinical quality to HRSA every year on a panel most practices never see: 18,089 patients, two-thirds of them homeless, more than half uninsured. The CY2025 report card shows an organization that screens, documents and follows up with rigor — on the measures a visit can control.
Nine of ten patients screened and counseled — on a panel that is among the hardest to reach in the country.
Screening with a documented follow-up plan, run at scale alongside a full behavioral health service line.
2,234 of 2,766 patients with cardiovascular risk on statin therapy — prevention working where it is hardest to deliver.
Founded by the Sisters of Mercy in 1985, Mercy Care is Atlanta's Health Care for the Homeless grantee — clinics inside Gateway Center, City of Refuge and the Salvation Army, and teams that go to the encampments.
OCHIN Epic across all sites and providers, a MyChart portal, kiosks, automated outreach for care-gap closure, and 7,173 patients screened for social needs with results structured in the chart.
A 19-bed men's unit at Gateway Center and a 14-bed women's unit at City of Refuge give discharged patients a place to recover — post-hospital transition care, already staffed and running.
Blood pressure and blood sugar are decided in the weeks between appointments — medication taken or missed, symptoms caught or not. For a panel where housing itself is unstable, the visit-based ceiling arrives early. Mercy Care's own CY2025 submission shows exactly where.
Up 28% since 2021. The panel these programs bill on — and the one slice of Mercy Care's population whose care management pays fee-for-service from day one.
Nearly two-thirds of the Medicare panel also carries Medicaid. That drives the top APCM payment tier, and it removes the out-of-pocket barrier to enrollment for most patients.
The aging-in pipeline. Nearly three times the current Medicare panel is approaching eligibility, so every ceiling in this model rises each year.
G0511 — the single bundled code that paid health centers one flat amount for roughly twenty distinct care-management services — is gone. Since January 1, 2026, federally qualified health centers bill the individual CCM, RPM and APCM codes at national non-facility Physician Fee Schedule rates, each separately payable in addition to the PPS encounter rate.
PPS still pays for the visit. Care management and remote monitoring pay on top of it rather than folding into it, so a remote-care program does not cannibalize the encounter.
These codes pay the same national amount at every Mercy Care site — Decatur Street, Chamblee, the shelter clinics, the mobile units. The rate card is set in Washington, not by the locality index.
Each program now needs its own time capture and its own documentation, every month, for every enrolled patient. That is the operational cost of the change, and it is the part CoachCare absorbs.
Modeled across the 1,132 Medicare patients in Mercy Care's CY2025 panel — the population where these codes pay at Medicare rates. CoachCare supplies the devices, the enrollment staff, the monitoring hours and the documentation. The health center supplies the panel and the clinical decisions.
Remote physiologic monitoring. Cellular blood-pressure cuffs and glucose meters that transmit on their own — no smartphone, no WiFi, no fixed address required. 99453 setup, 99454 device supply, 99457 and 99458 treatment management, plus the CY2026 short-window codes 99445 and 99470. Reaches 65% of the panel and stacks with either care-management rail.
Chronic care management. Monthly non-face-to-face management for patients with two or more chronic conditions — in a panel with 3,819 hypertension and 1,939 diabetes diagnoses, that is most of the Medicare population. 99490 and 99439.
Advanced primary care management. No minute thresholds and no time sheets — a monthly per-patient payment tiered by complexity. G0556, G0557 and G0558, where the top tier pays most for qualified Medicare beneficiaries who also carry Medicaid. 714 of Mercy Care's 1,132 Medicare patients — 63.1% — are dual-eligible, which points this panel at the strongest APCM tier there is.
The enrollment model meets patients where Mercy Care already does — at the clinic, at the shelter, at the respite bed, through the mobile units. One CoachCare-funded specialist works the highest-volume sites while telephonic outreach covers the rest, and enrollment materials are built plain-language first: more than a third of Mercy Care's patients are best served in a language other than English.
Mercy Care runs OCHIN Epic at every site, with MyChart, kiosks and automated care-gap outreach already live. CoachCare builds on Epic's own workflows, so the care team enrolls and monitors patients without learning a second system. Readings, documentation and claims all land in the chart the clinicians already work in.
Enrollment flags and trigger ordering sit inside the clinical workflow. The CoachCare team enrolls qualified Medicare patients on the health center's behalf, and enrollment status is visible in Epic in real time.
Bi-directional at intake, so the care team starts with the same problem list, medications and history the clinic has.
Blood pressure, weight and glucose readings post as structured data on the patient record rather than as attachments nobody opens.
An integrated care summary lands in the record. Under the CY2026 individual-code rules each program needs its own time capture and its own documentation, and this is what substantiates the billed time when a payer asks.
Claims are created by the CoachCare billing engine. CoachCare is the only care-management application integrated with Epic that generates claims automatically, which removes the manual per-patient, per-month claim step entirely.
The economics prove the service line pays. This is what keeps it safe — and what lets 14 busy clinicians delegate monitoring without inheriting noise.
The care team retakes it and screens for symptoms before anything escalates. A single high number is a measurement; a confirmed one is a finding.
A patient who feels fine with a critical reading still escalates. Feeling well is not a reason to wait.
Three readings at least an hour apart for blood pressure or glucose, or three within seven days for heart rate. Not a judgment call, and not a different threshold depending on who is working.
Voicemail and a callback attempt are logged, and a critical value or confirmed trend escalates anyway. Silence never closes a case — a discipline this panel demands more than most.
Emergencies go to 911. Non-critical findings go to a named member of the practice team. Stable and resolved goes into the record as an FYI, so the clinic is not paged for readings that resolved themselves.
Vital, findings, method of contact, who was reached, outcome, and follow-up. That record is also what substantiates the billed time.
A 24-month forecast across the 1,132-patient Medicare panel, 14 referring adult-medicine clinicians, one CoachCare-funded on-site enrollment specialist, telephonic enrollment, and CY2026 national non-facility PFS rates. Grant revenue, Medicaid and the dollar value of avoided admissions are not in these numbers.
| Program | Year 1 | Year 2 | 24‑Month |
|---|---|---|---|
| RPM net reimbursement | $209,142 | $298,078 | $507,220 |
| CCM net reimbursement | $143,540 | $180,612 | $324,152 |
| APCM net reimbursement | $89,195 | $99,593 | $188,788 |
| Total net reimbursement | $441,878 | $578,283 | $1,020,160 |
| CoachCare fees (incl. one-time) | $260,042 | $329,124 | $589,166 |
| Net to the health center | $181,835 | $249,159 | $430,994 |
| Margin to the health center | 41.15% | 43.09% | 42.25% |
Roughly $520,000 of avoided acute cost over 24 months. That value accrues to payers and to the system, not to Mercy Care's revenue line, so it is excluded from every figure above.
Blood pressure, weight and glucose readings arriving between visits, where the hypertension and diabetes measures are decided.
Coded, documented and submitted with the time capture the CY2026 individual-code rules require.
About 3.2 full-time equivalents of care-management capacity, added without the health center hiring anyone.
The forecast above covers 1,132 Medicare patients. Mercy Care serves 18,089 — and the devices, the escalation engine and the enrollment staff built for the Medicare rail are the same ones the whole mission can use. What differs is the payment rail, and Georgia's is specific.
Georgia Medicaid does not reimburse remote patient monitoring as a separate service, and care management sits inside the encounter. That is exactly why the sequencing starts with Medicare — the rail that pays code by code from month one, at every site.
3,118 patients aged 55–64 sit behind a Medicare panel that has grown 28% since 2021 — and 270 units of affordable housing are rising next to the Decatur Street clinic. Every ceiling in the model moves up each year without a single new patient acquired.
Continuous blood-pressure and glucose data moves the UDS quality measures, strengthens every grant narrative with documented longitudinal touch, and extends naturally to the respite beds and street-medicine follow-up — on Mercy Care's terms, at Mercy Care's pace.
Pull the exact Medicare and dual-eligible count from the practice management system, submit the interface request into the OCHIN queue, and agree which sites start — Decatur Street and Chamblee carry the deepest Medicare concentration.
Enrollment flags and trigger orders built into the existing workflow, discrete vitals mapped to the chart, escalation routing set to Mercy Care's own contacts, documentation templates mapped to the CY2026 individual-code requirements, plain-language multilingual enrollment materials, cellular devices staged, and the on-site enrollment specialist placed.
Enrollment begins in month 1 — there is no dormant onboarding period. Telephonic outreach and the shelter clinics extend reach beyond the flagship sites from the start.
APCM reaches its ceiling in month 3, CCM in month 5 and RPM in month 8. From there the program grows with the panel itself — the aging-in pipeline is three times the current Medicare panel — and the conversation turns to the respite beds, the housing development, and the rest of the mission.
Over 400 managed conditions.
Providers running remote care programs day to day.
Programs stood up and running in market.
Care-plan coding and billing behind more than five million claims.
Over 100 million vitals recorded and more than 4 million care actions enabled.