RCMS is CHMS's proprietary care intelligence platform. It's what powers every CCM program we run — condition-specific questions, algorithm-tied scoring, and real care coordinators backed by AI, moving patients through their care pathway instead of just logging a monthly phone call.
Every patient interaction feeds a clinical intelligence engine that decides what happens next — turning a monthly check-in into a continuously managed care pathway. The loop never stops: coordinator conversations train the model, and the model sharpens every coordinator's next conversation.
Condition-specific questions, pulled from a structured set built for the patient's exact diagnosis.
Algorithm-tied scoring converts every response set into an objective, comparable severity score.
Targeted action items are generated automatically — a real task, with an owner and a reason.
Escalation-triggered alerts notify the care team and provider the moment a threshold is crossed.
Coordinators don't read from one generic script. Each call pulls from a structured question set built for the patient's specific diagnosis — so every conversation surfaces the clinical detail that actually matters for that condition.
Every response set runs through a condition-specific scoring algorithm — converting a conversation into an objective, comparable severity score, instead of leaving risk to an individual coordinator's judgment call.
Two coordinators scoring the same answers reach the same result — every time.
Scoring logic reflects what actually predicts risk for that diagnosis, not a generic checklist.
Scores are the input that later triggers targeted actions and escalation alerts.
A score alone doesn't help a patient. Every scored encounter converts into a specific, assigned next step for the coordinator — a real task tied to that patient's condition, not a generic "follow up next month" note.
When a score crosses a defined clinical threshold, the system fires a real-time alert to the care team and provider automatically — so a declining patient doesn't wait for their next scheduled call to be noticed.
Condition-specific check-in is completed.
The algorithm applies condition-specific risk weighting.
The escalation rule fires instantly — no manual review needed.
The care team and provider are alerted the same day.
Patients aren't just monitored — they're mapped to a defined clinical pathway for their diagnosis. For example, after a set trial period on second-line medication with no meaningful improvement, the system automatically flags an Overactive Bladder patient to advance to the next stage of therapy.
No improvement after 8–12 weeks on second-line medication flags the patient for Botox, PTNS, or SNM.
Meaningful improvement within the trial window keeps the current plan in place and re-evaluates next cycle.
New or worsening red-flag symptoms trigger an urgent provider alert, regardless of pathway stage or trial timing.
Overactive Bladder is shown here as one example. Pathway logic is built per diagnosis — BPH, CKD, active surveillance, and other condition-specific pathways work the same way.
Every patient's condition score is tracked over time, producing an objective improvement or decline trend — real clinical signal to share with referring providers, support quality reporting, and prove the program's impact.
The clinical intelligence layer doesn't just satisfy CMS requirements — it changes what the program actually does for patients and the practice.
Fully documented time, consent, and care-plan requirements — billing-ready by design.
Patients actively progress through their condition's care pathway, not just log minutes.
Score-triggered alerts catch decline and notify the care team in real time.
Escalations and pathway steps route patients back into the clinic when it matters.
Consistent coordinators and proactive outreach patients actually notice and value.
RCMS is the engine — Chronic Care Management is where patients feel it. Explore the full program, or talk to our team about what this looks like for your practice.
