Diabetes Care Program

Our licensed care team helps patients manage diabetes using RPM and CCM programs that fit right into your existing workflows.

• Integrates with your EHR
• Certified diabetes educators and registered dietitians
• Real-time glucose monitoring for proactive care

Call now: 914-420-1023 | Schedule Your Free Diabetes Program Demo

The Growing Burden of Diabetes in the U.S

More than 38 million Americans are living with diabetes. Among Medicare-eligible patients, nearly half are affected by diabetes or prediabetes—making it one of the most common chronic conditions in senior care across the country.

What makes diabetes especially dangerous is how easily it can go unnoticed. Without real-time diabetes monitoring and consistent support, even the most compliant patients can experience sudden spikes or drops in glucose levels—potentially leading to hospitalization or long-term complications.

Diabetes is a leading cause of preventable complications and often contributes to emergency visits or hospital readmissions when not properly managed. Traditional in-person care alone doesn’t meet the daily needs of diabetic patients. That’s why the RPM & CCM Health Diabetes Care Program provides consistent, proactive diabetes care from the comfort of the patient’s home—helping your practice improve outcomes and unlock reliable monthly revenue.

Without consistent diabetes remote monitoring and support, effective diabetes management becomes difficult. Our program bridges that gap through integrated RPM and CCM services designed to keep patients on track.

What’s Included in Our Diabetes Care Program

Our comprehensive Diabetes Management Program delivers tailored clinical, educational, and administrative support to meet each patient’s unique needs. While technology plays a role, it’s human-centered care that truly makes a difference—and we deliver it at scale.

Ensuring Clinical Support 

• Continuous glucose tracking with CGM devices (Dexcom, Libre)
  
• Monthly follow-ups and health coaching from certified professionals
  
• Medication monitoring, refill coordination, and side effect management
  
• Coordination with primary care providers or endocrinologists

Educational and Lifestyle Coaching for Diabetes Management

• Nutrition planning tailored for diabetes by registered dietitians
  
• 1:1 counselling with certified diabetes educators
  
• Support for weight management and physical activity goals
  
• Access to virtual support groups and lifestyle webinars
  

Streamlining the Administrative and Patient Experience

• A dedicated care coordinator assigned to every patient
  
• Secure, branded microsite access for patients and their caregivers
  
• Automated scheduling, reminders, and documentation
  
• Optional transportation assistance for in-office visits

Our chronic care management for diabetes makes it easy for providers to participate without adding extra work to their staff. From medical device distribution to patient engagement and billing, everything is managed by our experienced team.

Real-Time Monitoring + Monthly Support = Better Outcomes

Remote patient monitoring for diabetes helps healthcare providers stay connected with patients—even outside of regular clinical hours. With real-time CGM data synced directly to your EHR, our system enables early interventions and timely support that reduce risk and enhance quality of life.

When paired with monthly chronic care management, your patients receive consistent, structured support from our diabetes care team nurses—including registered dietitians and certified diabetes educators. This team focuses on A1C reduction, weight control, and personalized guidance through each patient’s diabetes care plan.

Our practice follows the latest CPT codes for RPM (99453, 99454, 99457, 99458) and CCM (99490, 99439, 99487, 99489) to ensure every clinical encounter is accurately documented and fully reimbursed.

Diabetes Management CPT Codes That Pay You Monthly

Reimbursement rates vary by region and payer.

Who Benefits From Our Diabetes Care Program?

Our end-to-end RPM diabetes education and support program is scalable to meet the needs of diverse healthcare providers and patient populations. Whether you’re managing chronic conditions in a busy urban clinic or delivering essential care in rural communities, our flexible platform empowers you to provide proactive, ongoing support.

• Primary care physicians
  
• Endocrinologists
  
• FQHCs and RHCs
  
• Medicare-eligible patients with Type 1, Type 2, or prediabetes
  
• Clinics struggling with patient adherence

“We saw a significant drop in diabetes-related readmissions within the first six months. The RPM & CCM Health team feels like an extension of our staff.” — Dr. L. Jones, Internal Medicine. 

How Patients Enroll and Stay Engaged

Our Medicare diabetes support services workflow is both simple and responsive. Every step combines reliable technology with personalized human interaction—helping patients stay on track while keeping providers consistently connected.

Enrollment: A nurse or medical assistant enrolls eligible patients during an office visit or outreach call. Key information is collected to ensure a high standard of care from the start.

Device Setup: A CGM (Continuous Glucose Monitor) is either shipped directly to the patient’s home or set up during a clinic visit. Clear instructions and hands-on training are provided to ensure proper use from day one.

Monthly Touchpoints: Patients receive monthly check-ins with registered dietitians, nurses, or certified diabetes educators. These sessions reinforce healthy habits, address individual concerns, and help build lasting trust between patients and care teams.

24/7 Monitoring: Our platform continuously tracks glucose readings in real time. Providers receive daily alerts for out-of-range values or concerning trends, allowing for timely, proactive interventions.

Ongoing Adjustments: Using real-time patient data and insights from monthly consults, care teams can make informed changes to a patient’s diet, exercise routine, or medications. Every update is documented and shared with both the patient and their provider to ensure continuity of care.

Your Success Is Measured by Real Outcomes

Our diabetic care program goes beyond checking boxes—it focuses on preventive measures that support real-time patient well-being. Our RPM diabetes devices are built to deliver better health outcomes, stronger patient relationships, and lasting financial value for your practice.

• A1C Reduction tracking: A1C levels are tracked over time, giving providers clear insights into trends and enabling timely adjustments to support better outcomes.
• Drastic reduction in hospitalization: Ongoing monitoring and patient outreach can help prevent unnecessary ER visits—reducing costs and improving overall quality of life.
• Medication Adherence: Timely check-ins help patients stay consistent with their prescriptions and follow their treatment plans more reliably.
• Increased patient satisfaction: Patients feel seen, supported, and genuinely cared for—leading to higher satisfaction scores and stronger long-term loyalty to your practice.

Frequently Asked Questions 

What devices are included in your diabetes program?

We provide cellular-embedded continuous glucose monitors (CGMs) and other compatible devices that automatically transmit data in real time.

Are your dietitians and educators certified?

Yes. Our care team includes licensed registered dietitians (RDs), CDCES-certified diabetes educators, and experienced registered nurses—all specializing in diabetes management and patient coaching.

Can this be used for both Type 1 and Type 2 diabetes?

Absolutely. Our program supports patients with Type 1 diabetes, Type 2 diabetes, and prediabetes. Each care pathway is personalized based on the patient’s diagnosis, needs, and risk factors.

Ready to Elevate Your Diabetes Care?

Let’s transform the way you support diabetic patients—while unlocking steady monthly revenue for your clinic. Whether you’re just exploring or ready to launch, we’re here to help you take the next step.

Get a Free Diabetes Program Demo
Download the CPT Billing Guide