Connected Monitoring. Coordinated Care.

Extend Care Beyond the Visit

MonitorCare helps physician groups and health systems deliver end-to-end remote monitoring and care management services that:

Reduce avoidable 30-day readmissions and ED visits.
Meet quality and value-based care metrics.

Designed for Every Stage of Care

For Hospitals
  • Reduce 30-day readmissions
  • Decrease avoidable emergency visits
  • Improve post-discharge outcomes
  • Strengthen transitional care programs
For Physician Groups
  • Improve chronic disease management
  • Support quality measure performance
  • Increase patient adherence
  • Enhance continuity between visits

Condition-Specific Monitoring Programs

MonitorCare delivers structured, disease-focused remote monitoring programs aligned with established clinical guidelines. No Wi-Fi or Bluetooth setup needed.

Cardiovascular Disease Monitoring Program

Includes: CHF, CAD, HTN

Structured monitoring designed to detect early signs of deterioration and support timely intervention.

Key Elements
  • Daily monitoring of weight, blood pressure, and heart rate
  • Symptom tracking (dyspnea, edema, fatigue)
  • Early detection of worsening condition
  • Medication adherence support
  • Coordination with cardiology teams

COPD Monitoring Program

Guideline-aligned monitoring to prevent exacerbations and readmissions

Designed in alignment with GOLD and American Thoracic Society (ATS) recommendations, this program supports early detection and intervention following discharge.

Key Elements
  • Cellular pulse oximetry monitoring
  • Daily symptom tracking using mMRC dyspnea scale
  • Early detection of respiratory deterioration
  • Patient education and adherence support
  • Coordination with pulmonology teams

Diabetes Monitoring Program

Continuous glucose visibility during the highest-risk transition period

Patients are equipped with CGM (Continuous Glucose Monitoring) patches at discharge, enabling real-time insight into glucose trends and early intervention.

Key Elements
  • CGM deployment at discharge
  • Continuous glucose monitoring
  • Detection of hypo- and hyperglycemic events
  • Patient engagement and adherence support
  • Coordination with primary care and endocrinology

How It Works

Our streamlined 5-step process
1
Identify and enroll patients
2
Deploy monitoring devices
3
Continuous data tracking
4
Early detection of issues
5
Care coordination and follow-up

Why healthcare organizations partner with MonitorCare

Better Clinical Visibility

Gain timely insight into patient status through connected monitoring and structured follow-up workflows.

Stronger Care Coordination

Support continuity of care across the patient journey, including post-discharge and chronic care management.

Improved Patient Engagement

Keep patients connected to their care teams through education, outreach, and ongoing support.

Operational Readiness

Build programs that align with real clinical workflows, documentation needs, and payer program requirements.

Comprehensive care management and remote monitoring programs

RPM

Connected device-based physiologic monitoring for eligible patients.

RTM

Remote therapeutic monitoring for adherence and symptom tracking.

CCM

Ongoing support for patients living with multiple chronic conditions.

PCM

Condition-focused management for one serious chronic condition.

TCM

Structured follow-up during the post-discharge transition period.

Care Coordination

Integrated patient engagement and care pathway support.

Helping organizations support patients beyond the point of care

Healthcare organizations are under growing pressure to improve transitions of care, manage high-risk populations more effectively, and support patients between visits.

MonitorCare helps providers operationalize programs that strengthen patient connection, surface actionable information, and support earlier clinical follow-up when needed.

Post-Discharge Monitoring Chronic Disease Management Care Transitions High-Risk Populations

Connected Care Model

Hospital / Clinic / Medical Group
MonitorCare Platform + Services
Monitoring · Coordination · Engagement · Documentation
Patient at Home

Built for organizations managing complex patient populations

Hospitals & Health Systems

Supporting post-discharge monitoring and improving continuity of care at scale.

Learn more →

Physician Groups & Clinics

Helping practices manage chronic and high-risk populations with operational efficiency.

Learn more →

Specialty Practices

Extending care between visits for patients with ongoing monitoring and coordination needs.

Learn more →

More than a platform — a care delivery partner

We combine program support, workflow execution, and patient engagement into one aligned service model.

  • End-to-end program support
  • Scalable service model
  • Clinical workflow focus
  • Compliance-conscious approach
  • Patient-centered engagement

Program Support

From onboarding to ongoing monitoring — we support the full service lifecycle, not just the technology layer.

Clinical Workflow Alignment

Our services fit the realities of provider operations, designed around how care teams actually work.

Compliance-Conscious Execution

We approach implementation with awareness of documentation standards, payer rules, and patient consent requirements.

Ready to strengthen your remote care strategy?

Whether you are building a new program or scaling an existing one, MonitorCare helps you move from concept to execution.

One Platform. Two Critical Outcomes.

MonitorCare helps healthcare organizations operationalize scalable care programs that support patient engagement, care continuity, and day-to-day clinical visibility.

For Hospitals

  • Reduce 30-day readmissions
  • Decrease avoidable ED utilization
  • Improve post-discharge outcomes
  • Strengthen transitional care programs

For Physician Groups

  • Generate recurring RPM & CCM revenue
  • Meet quality and value-based care metrics
  • Improve patient adherence
  • Reduce staff workload

A connected service model designed to support both patients and providers throughout the care journey

01Identify
02Enroll
03Monitor
04Engage
05Escalate
06Document
RPM

Remote Patient Monitoring

Connected physiologic monitoring for eligible patients using device-generated data.

What it is

RPM uses connected devices to collect and transmit patient health data — such as blood pressure, glucose levels, weight, or oxygen saturation — enabling care teams to monitor patients outside of traditional clinical settings.

How MonitorCare supports it:

  • Patient enrollment and device coordination
  • Monitoring workflow management
  • Alert handling and escalation protocols
  • Patient outreach and engagement
  • Documentation coordination
Typical Use Cases
  • Hypertension management
  • Diabetes monitoring
  • Cardiac support programs
  • Post-discharge monitoring

RPM programs can help care teams stay connected with patients managing ongoing conditions, providing timely data to inform clinical decision-making between office visits.

RTM

Remote Therapeutic Monitoring

Monitoring therapeutic adherence, response, and patient-reported data for clinically eligible patients.

What it is

RTM captures non-physiologic data — including medication adherence, pain levels, and functional status — to support care teams managing patients with therapeutic and musculoskeletal needs.

How MonitorCare supports it:

  • Patient onboarding and education
  • Adherence monitoring workflows
  • Symptom data collection support
  • Care team communication coordination
Typical Use Cases
  • Respiratory care management
  • Musculoskeletal recovery support
  • Medication adherence tracking
  • Symptom pattern monitoring
CCM

Chronic Care Management

Monthly structured support for patients managing multiple chronic conditions.

What it is

CCM provides ongoing care coordination and support services for patients with two or more chronic conditions, helping them stay engaged with their care plans and care teams between visits.

How MonitorCare supports it:

  • Monthly outreach and patient engagement
  • Care plan support workflows
  • Coordination across care team members
  • Documentation and reporting support
Key Emphasis
  • Patients with 2+ chronic conditions
  • Ongoing structured coordination
  • Monthly engagement touchpoints
  • Long-term relationship support
PCM

Principal Care Management

Condition-focused management support for patients with one serious chronic condition.

What it is

PCM offers intensive, focused care management for patients with a single high-complexity chronic condition, providing structured engagement and coordination specific to that condition.

How MonitorCare supports it:

  • Condition-specific care plan support
  • Focused patient engagement workflows
  • Documentation and eligibility support
  • Coordination with specialty care
Key Emphasis
  • Single high-severity chronic condition
  • Deeper engagement than standard CCM
  • Specialty-aligned workflows
  • Focused clinical goal support
TCM

Transitional Care Management

Supporting patients during the critical transition period following hospital discharge.

What it is

TCM provides structured outreach and coordination support in the days and weeks following a hospital discharge, helping to reduce readmission risk and ensure patients reconnect with their care teams.

How MonitorCare supports it:

  • Post-discharge outreach coordination
  • Care transition workflow support
  • Follow-up appointment coordination
  • Medication and care plan reinforcement
  • Documentation support
Key Emphasis
  • Time-sensitive post-discharge support
  • Outreach within 2 days of discharge
  • Face-to-face or telehealth follow-up
  • Coordination with inpatient teams

Additional program support services

Patient Onboarding
Device Coordination
Patient Education
Monthly Outreach Support
Reporting Support
Workflow Alignment
Documentation Support
Escalation Pathways

Looking for a partner to operationalize multiple programs together?

MonitorCare helps integrate care management and remote monitoring into one aligned service model.

Built for Healthcare Organizations Managing Ongoing Patient Needs

MonitorCare partners with organizations that need scalable, patient-centered support for remote monitoring, care coordination, and post-visit engagement.

Hospitals & Health Systems

Physician Groups & Clinics

Specialty Practices

Care Management Organizations

For Hospitals and Health Systems

The Challenge

Supporting patients after discharge, improving continuity of care, and reducing avoidable utilization while managing large, complex patient populations across multiple settings.

How MonitorCare helps:

We help hospitals strengthen post-discharge monitoring and follow-up workflows so care teams can remain informed and responsive during critical transition periods.

Possible support areas:

Post-discharge monitoring High-risk patient visibility Care transition workflows Escalation support Patient outreach coordination

For Physician Groups and Clinics

The Challenge

Managing chronic and high-risk populations while maintaining quality outcomes and operational efficiency, often with limited staff capacity for ongoing patient outreach.

How MonitorCare helps:

We help physician practices implement remote care and care management programs that support engagement, continuity, and workflow-aligned service delivery.

Support areas:

CCMRPMRTMPCMTCM Patient engagement Documentation support Ongoing coordination

For Specialty Practices

Specialty providers often manage patients with ongoing monitoring and coordination needs. MonitorCare supports specialty-focused workflows that help extend care between visits.

Whether managing patients with cardiovascular disease, metabolic conditions, or pulmonary needs, our services can be aligned to the specific requirements of your specialty environment.

Supported specialties:

Cardiology Endocrinology Pulmonology Neurology Primary Care Multi-specialty Groups

For Organizations Expanding Care Delivery Capabilities

MonitorCare can support organizations seeking a full-service operational partner for patient engagement, monitoring coordination, and workflow execution.

Whether you are building out a new care management division or looking to scale an existing program, MonitorCare provides the operational infrastructure to support your goals.

What we bring to the partnership:

  • End-to-end operational support model
  • Multi-program execution capability
  • Patient engagement frameworks
  • Compliance-aligned workflows
  • Scalable service delivery

Let's discuss the needs of your organization

Every organization has different patient populations and care goals. We're ready to listen.

A Practical Partner for Connected Care Delivery

MonitorCare combines program support, workflow execution, patient engagement, and monitoring coordination to help healthcare organizations build and scale modern care management services.

What sets MonitorCare apart

We are not just a technology layer. We are an operational partner that supports the full service lifecycle of remote care programs.

01

End-to-End Support

From patient onboarding to monitoring workflows and care coordination, MonitorCare supports the full service lifecycle — not just the technology configuration.

02

Built Around Clinical Workflows

Our services are designed to fit the realities of provider operations, not just software dashboards. We align with how care teams actually function day-to-day.

03

Scalable Across Programs

We help organizations support RPM, RTM, CCM, PCM, and TCM under one connected model — reducing the operational complexity of running multiple programs.

04

Patient-Centered Engagement

Strong remote care programs depend on patient participation. We help create a more supportive, connected patient experience that encourages ongoing engagement.

05

Compliance-Conscious Execution

We approach implementation with awareness of documentation expectations, operational discipline, patient consent needs, and payer program requirements.

How MonitorCare supports implementation

1

Assess Organizational Goals

We begin by understanding your patient population, operational structure, and program objectives.

2

Define Service Model and Workflows

We work with your team to define the right service model and align workflows to your clinical and operational environment.

3

Support Patient Onboarding and Program Launch

We help coordinate patient identification, consent, enrollment, and device setup to support a structured program launch.

4

Coordinate Monitoring and Engagement Activities

Ongoing monitoring, patient outreach, alert handling, and care coordination are managed with operational discipline.

5

Support Reporting, Documentation, and Optimization

We support documentation workflows and help identify opportunities to improve program performance over time.

Designed for responsible program growth

MonitorCare is built to support healthcare organizations in implementing programs thoughtfully and responsibly.

We recognize that successful remote monitoring and care management programs require alignment with clinical judgment, patient eligibility, documentation standards, payer rules, and appropriate legal and compliance review.

Important notice:

MonitorCare supports program operations and workflow execution. Clinical decision-making remains with the treating provider. All program implementation should be reviewed against applicable regulatory, payer, and legal requirements.

Our commitment to responsible implementation

  • Alignment with payer program requirements
  • Documentation standards awareness
  • Patient consent and eligibility support
  • Operational discipline in workflow execution
  • Clinical decision-making stays with providers
  • Transparent partnership approach

Frequently asked questions

Do you support end-to-end implementation?
Yes. MonitorCare is designed to help organizations across planning, onboarding, monitoring, engagement, and operational follow-through.
Can services be tailored by organization type?
Yes. Our approach can be adapted for hospitals, physician groups, clinics, and specialty environments — each with different operational needs.
Do you replace clinical judgment?
No. We support workflows and patient engagement while clinical decisions remain entirely with the treating provider and their care team.

Choose a partner built for operational excellence and patient-centered care

We're ready to help you evaluate the right approach for your organization.

Let's Talk About Your Care Management Strategy

Whether you are exploring RPM, RTM, CCM, PCM, TCM, or a broader care coordination model, MonitorCare can help you evaluate the right approach for your organization.

I'm interested in:
Hospital post-discharge monitoring RPM program support CCM / PCM services RTM program support TCM support General partnership inquiry

Send Us a Message

Complete the form below and a member of our team will respond within one business day. All fields marked with * are required.

PHI Notice: Please do not submit patient-identifiable or protected health information (PHI) through this form. This form is intended for general program and partnership inquiries only.

Connect with MonitorCare

We take a consultative approach — every conversation starts with understanding your organization's specific needs and goals.

Mailing Address
PO Box 2565
Rockville, MD 20847
United States
Phone
Toll-free
Email
General inquiries & consultations
Business Hours
Monday – Friday
9:00 AM – 5:00 PM Eastern Time
About MonitorCare.org MonitorCare.org is a brand owned and operated by Maryland Medical Specialists, Inc., a Maryland-registered entity. All inquiries submitted through this site are received and managed by Maryland Medical Specialists, Inc.

A consultative conversation — not a sales pitch

Every organization has different patient populations, clinical goals, and operational constraints. We take time to understand your situation before recommending any approach.