CCM and RPM Together: How One Practice Grew Enrollment From 200 to 1,400+

For practices caring for many patients with chronic diseases, CCM and RPM work best when they are treated as part of the same care strategy. Chronic Care Management (CCM) and Remote Patient Monitoring (RPM) are separate programs, but they answer the same question: what happens to a patient between visits. That is what one high-volume endocrinology practice in San Antonio found as it grew its CCM enrollment from roughly 200 patients to more than 1,400.

Diabetes and Metabolism Specialists of San Antonio, Texas, serves about 60,000 patients with 10 providers and handles approximately 1,500 patient calls a day. Their growth did not come from one isolated change. It came from connecting CCM, RPM, and digital messaging so care teams could support more patients between visits while reducing phone-heavy manual work.

Why CCM and RPM Work Better Together

For practices managing diabetes, hypertension, obesity, metabolic conditions, and other chronic diseases, the need for better between-visit care is clear. According to the Centers for Disease Control and Prevention, three in four American adults have at least one chronic condition, and over half have two or more chronic conditions.

The CCM program supports monthly, non-face-to-face care coordination for eligible patients with chronic medical conditions, helping improve medication adherence and catch potential problems before they lead to adverse events or hospitalization.

The RPM program supplements such efforts by collecting personal health data from wearable devices between physical office visits. Having data such as blood pressure, weight, and blood glucose levels helps providers better monitor their patients’ conditions.

With eClinicalWorks Chronic Care Management and healow Remote Patient Monitoring, practices can pair ongoing care coordination with patient-generated health data. The care team is not waiting until the next appointment to see what is happening. They can review readings, follow up on medication questions, and support patients as part of a consistent care-management workflow.

The Practice: 60,000 Patients, 10 Providers, 1,500 Calls a Day

Diabetes and Metabolism Specialists is a high-volume specialty practice focused on endocrinology, diabetes, metabolic conditions, and weight management. Many of its 60,000 patients are elderly, and the practice sees about 220 patients per day.

That volume created a familiar challenge for many specialty groups: too much important work was tied to phone calls and manual follow-up. Shila McKnight, COO of Diabetes and Metabolism Specialists, described the operational burden clearly: “Earlier, verifying appointments could take an entire day.”

When a practice is already fielding about 1,500 patient calls daily, growing a care-management program requires more than clinical intent. It requires workflow capacity.

How CCM and RPM Took Enrollment From About 200 to More Than 1,400

According to the eClinicalWorks and healow customer story, “CCM enrollment increased from roughly 200 to over 1,400 patients.”

The results were clear:

• Monthly CCM check-ins helped the care team stay connected to patients outside scheduled visits.
• Medication follow-ups gave staff a structured way to support patients managing chronic conditions.
• healow RPM connected patients through scales, blood pressure monitors, and glucose devices.
• Messaging gave patients and staff another way to communicate without relying on every issue becoming a phone call.

Practices weighing care-management models can also compare CCM with the newer Advanced Primary Care Management (APCM) program in this CCM vs. APCM overview.

As McKnight said, “We’ve been able to respond to patients immediately and, in some cases, prevent hospital visits.”

Freeing the Phones: 28 Hours of Staff Time a Day

The care-management growth did not happen in isolation. eClinicalWorks Messenger played an important role by moving routine phone work into digital communication.

The practice reported: “Transitioning from manual phone workflows to digital communication using Messenger has reduced dependency on phone calls, increased face-to-face patient interaction, and saved 28 hours of staff time daily.”

For a practice handling about 1,500 calls daily, that time matters. It gives staff more room for outreach, appointment work and care management.

Messenger also helped reduce no-shows. McKnight said, “Previously, we would see about 7-8 no-shows or late cancellations per provider. Now, we see one no-show per provider since enabling Messenger.”

For practices focused on missed appointments, these AI-driven no-show reduction strategies offer related ideas.

What Other Practices Can Learn

The Diabetes and Metabolism Specialists story offers practical lessons for other practices that want to grow care-management programs.

1. First, free phone capacity before scaling enrollment. If staff are consumed by calls, it is hard to expand monthly outreach and follow-up.
2. Second, pair device data with a care program. RPM readings are most useful when the care team has a regular process for reviewing and acting on them.
3. Third, give patients a faster way to respond. Messaging can reduce phone dependence and help patients complete routine communication more easily.
4. Finally, use enrollment growth as an operations measure. Going from about 200 to more than 1,400 CCM patients required both clinical commitment and workflow change.

Practices considering remote monitoring can also review how RPM supports cardiac care.

Frequently Asked Questions (FAQ)

Can You Bill CCM and RPM Together?

Check current guidance before building a workflow around it. CMS states that “you can bill either remote physiologic monitoring (RPM) or remote therapeutic monitoring (RTM), but not both, concurrently with any CCM or TCM service.” Billing rules change, so confirm the current year’s guidance with your billing team.

What Is the Difference Between Chronic Care Management and Remote Patient Monitoring?

CCM is monthly, non-face-to-face care coordination for patients with chronic conditions: check-ins, medication follow-up and care-plan work. RPM collects patient-generated readings from connected devices between visits, such as blood pressure, weight and blood glucose. One is the coordination program, the other is the data that informs it.

What Does a Practice Need to Run CCM and RPM at Scale?

Phone capacity first, then a repeatable review process. Diabetes and Metabolism Specialists moved routine phone work into digital messaging before growing enrollment, then paired device readings with monthly outreach so someone reviewed and acted on them. Enrollment growth follows the workflow rather than the other way around.

CCM and RPM work best when they are supported by clear workflows, timely communication, and a care team that can act between visits. To learn more, visit eClinicalWorks Chronic Care Management or read the full Diabetes and Metabolism Specialists story