Connected Care in Rural Health with RPM, CCM, and Telehealth
Connected care combines technology, communication systems, and data sharing to create a connection between patients, providers, and caregivers. It’s not a new care management model, but it is proven to positively impact patients and providers while creating added sources of revenue. Care coordination involves different types of providers working together to ensure all of a patient’s providers are aware of their current medications and health status, and that all aspects of the patient’s care are effectively managed.
Advances in technology, communication systems, and data sharing today, make a range of connected care approaches possible. And rural hospitals, clinics, and providers can implement connected care with little or no added investment, staff, or time. It can improve communication among providers, strengthen patient engagement, and reduce costs for organizations and patients and create a more efficient care model. And new or proposed Centers for Medicare & Medicaid Services (CMS) policy changes for 2026 could make connected care even easier and more cost-effective.
“[With connected care,] you’re able to do more with your existing resources. We know from the claims data that these are highly underutilized codes. Very small single-digit percentages of patients that are eligible to receive these services are receiving them today,” said Shane Grivich, cofounder and chief strategy officer (CSO) of ChartSpan, an Azalea Health partner.
The Value of Connected Care in Rural Areas
With any new service model or CMS update, there are operational needs. As you move to or consider a connected care model, know that:
- Assess current workflows and integration opportunities
- Ensure providers and billers understand new and revised CPT codes
- Update or optimize telehealth and RPM workflows/tools (a third-party partner can help)
- Integrate data into your EHR and reporting
- Assign a program owner/main point of contact (especially with outside partners)
- Shift responsibilities between staff and clinicians as needed
- Ensure capacity for increased patient touchpoints (or partner for scale)
- Educate patients and care teams on new technologies and engagement expectations
The benefits of connected care include improved communication, greater patient engagement, and cost savings for both staff and patients.
Rural Connected Care with RPM, CCM, and Telehealth
Connected care includes the EHR, patient engagement tools, care coordination platforms, AI, chronic care management (CCM), telehealth, and remote patient monitoring (RPM) — most of which aren’t yet widely adopted in rural settings. These tools can connect care teams and patients across settings and create a more continuous care experience — making them ideal for rural care. And new or proposed CMS updates may make connected care more attractive for rural providers.
The Future of RPM
CMS has adopted new billing codes for how long patient data has to be collected and how long providers have to interact with patients. The changes make RPM a more adaptable tool for managing chronic and other conditions and improving outcomes. Changes create added clinical flexibility, broader patient pools, and more scalable models for telehealth.
RPM data was previously collected 16 out of every 30 days (CPT 99454). The new rule includes an added code, 99XX4, for 2- to 15-day collection and makes using RPM easier. It modifies 99454 to cover 16 to 30 days.1 Both codes have the same reimbursement rate and should reduce denials, add billing options, and increase the patient pool.1
Before, providers had to engage with RPM patients for 20 minutes a month (CPT 99457). The new rule adds a 10 to 19 minute engagement option (code 99XX5) reimbursed at half of CPT 99457.1 Shorter-duration codes let providers bill for meaningful clinical intervention, such as responding to alerts, reviewing patient data, or adjusting medications that only take a few minutes.
The Future of CCM and Advanced Primary Care Management
CMS changes for 2026 for chronic care management reflect CMS’s commitment to modernize care delivery while addressing the burden of chronic disease.2
The rule simplifies integrating behavioral health treatment into Advanced Primary Care Management (APCM) to treat both physical and mental health as part of chronic disease management.
The rule moves from the previous 10 quality measures to 5 new outcome measures. The new measures focus on chronic disease prevention, including prescreening for diabetes. They also align payment incentives with health improvements for patients with chronic conditions.
CMS also broadened payment policies for digital mental health treatment devices, such as software used on phone apps, tablets, or computers.
Combined, these changes emphasize data-informed policymaking and using technology for chronic care management, which makes care more accessible and easier to administer.
The Future of Telehealth
CMS changes for 2026 outline restructuring telehealth policies with a mix of permanent expansions and the end of temporary COVID-19 policies.
CMS expanded Medicare coverage for telehealth services. This removes the distinction between provisional and permanent services and expands services that can be done using an interactive, two-way audio-video telecommunications system.
Changes let supervising physicians oversee visits by real-time audio-video technology instead of being physically present.
CMS also permanently removed frequency limits for follow-up inpatient visits, nursing facility visits, and critical care consultations to provide more flexibility for ongoing patient care over telehealth.
These changes increase patient access and provider flexibility and create new revenue streams for rural providers. And connected workflows can integrate device data and secure messaging to support ongoing follow-up and care team coordination.
We know from the claims data that these are highly underutilized codes. Very small single-digit percentages of patients that are eligible to receive these services are receiving them today.”
Potential Barriers to Connected Care
There are some barriers for rural hospitals, clinics, and providers that want to take advantage of connected care. A lack of high-speed internet options is a barrier for roughly 23% of people in rural communities.3 Investing in RPM equipment also has an upfront cost. And some populations, such as the elderly, may not be as digitally literate and struggle to use devices without help.
To overcome barriers, focus on training, implementation support, and a phased rollout, especially for staff workflows and patient onboarding.
Operational Considerations with Connected Care
With any new service model or CMS update, there are operational needs. As you move to or consider a connected care model, know that:
- Assess current workflows and integration opportunities
- Ensure providers and billers understand new and revised CPT codes
- Update or optimize telehealth and RPM workflows/tools (a third-party partner can help)
- Integrate data into your EHR and reporting
- Assign a program owner/main point of contact (especially with outside partners)
- Shift responsibilities between staff and clinicians as needed
- Ensure capacity for increased patient touchpoints (or partner for scale)
- Educate patients and care teams on new technologies and engagement expectations
The benefits of connected care include improved communication, greater patient engagement, and cost savings for both staff and patients.
The 2026 Definitive Guide to Rural Healthcare
Essential topics for every rural healthcare leader,
Sources
3 U.S. Department of Agriculture (USDA), Broadband
About the Author
