CoachCare brings a complete operating system: the software platform, proprietary devices and SIM cards, end to end device logistics, a US-based W-2 care team, and the analytics engine (Tableau).

Cardiology Experience

Cardiology is your specialty. Serving cardiologists and their patients is ours.

CoachCare currently works across 60+ ambulatory cardiology sites and 30+ customers.

Athena Integrated

Complete, bi-directional integrations with both athenaPractice and athenaOne.

CoachCare is purpose built to serve large cardiology groups and their patients.

01.2 · A partnership model built to scale profitably

AHVI supplies the patients and the clinical authority. CoachCare supplies everything else.

There is no capital request in this proposal and no hiring plan attached to it. CoachCare funds the enrollment specialists who sit in AHVI clinics, employs the care team, owns the devices and carries the cost of the platform. AHVI bills under its own NPIs and keeps the payer relationship.

AHVI CoachCare Teal arrows: the exceptions that rise to an AHVI clinician

One patient across five stages. AHVI identifies the patient and signs the order, then provides clinic space and the introduction. CoachCare surfaces eligible candidates in the chart, enrolls at the point of care, matches and ships the device kit, and works every reading. Equipping the patient needs nothing from AHVI at all. Two things rise back to AHVI: medical decision making on the exceptions CoachCare escalates, and billing, which AHVI does under its own NPIs while holding the payer relationship and the revenue.

Up-front capital outlay. No device purchase, no platform license, no implementation fee carried by AHVI.

Net-new AHVI FTEs required. The care team and the enrollment specialists are CoachCare headcount.

36.8

FTE equivalents of care management CoachCare performs over 24 months. That is 76,603 staff hours AHVI never has to recruit or retain in an Anchorage labor market.

01.3 · Operational readiness

The two things that actually decide whether a program launches on time.

Devices and connectivity

Cellular first, so home internet is not a prerequisite

Devices arrive configured and paired and transmit over cellular. A patient needs no smartphone, no app pairing and no home internet. That is the difference between a program that runs statewide and one that runs inside the Anchorage bowl.

Full detail in Section 03 →

EHR integration

Complete and bi-directional, on athenahealth, through the athenaOne transition

Readings, care management notes and billing-ready documentation land in the chart the physician already opens. AHVI's move from athenaPractice to athenaOne is a switchover CoachCare has run before, so it is not a reason to wait.

Full detail in Section 05 →

01.4 · The clinical model

Cardiology is the deepest part of the CoachCare book.

Over 40 cardiology customers run remote care on CoachCare today, including Cardiac Solutions, Western Washington Medical Group, MercyOne / Iowa Heart, and AMS Cardiology. The model below is what those programs look like in operation. Two of those names carry published outcomes, and they close this section.

The AHVI pod

A named care team that belongs to AHVI, not a shared queue

The pod is staffed to AHVI, learns AHVI's protocols and escalation preferences, and is known to the clinic by name. Three on-site enrollment specialists sit in AHVI clinics and enroll patients at the point of care. Telephonic outreach converts at roughly 8%, so on-site enrollment is what actually gets a program to census.

Care team ratio

160:1 300:1

CoachCare staffs at roughly 160 patients per care team member against an industry average near 300:1. Ratio is the variable that decides whether remote monitoring is clinical management or a data feed nobody reads.

Filtering signal from noise

700,000 readings become a handful of conversations that need a physician.

These are forecast volumes across 24 months for the AHVI program. Every step down is work CoachCare absorbs, so what reaches an AHVI physician or APP is top of license.

Vitals readings
transmitted

702,630

Care management
tasks worked

337,876

Chart updates
written back

84,469

Patient
conversations

50,681

Reaches an AHVI
physician or APP

63 / month

Forecast volumes over 24 months from go-live, for the modeled AHVI program: 702,630 readings, 337,876 care management tasks, 84,469 chart updates and 50,681 patient conversations. Of that, roughly 63 escalations a month reach an AHVI clinician at 6,942 enrolled patients, which is 0.9% of the enrolled panel.

Connective tissue across service lines

The same monitored population is a standing patient-identification engine for the procedural service lines.

Structural heart: TAVR

Symptom and vitals trends surface progression in monitored aortic stenosis patients between clinic visits.

CABG & PCI

Post-discharge weight, blood pressure and medication adherence tracked through the window where readmissions happen.

Renal denervation

Documented, device-captured blood pressure over time is the evidence base the referral conversation needs.

Heart failure clinic

Daily weights and symptom checks give the HF clinic and the APP team a continuous view between titration visits.

Experience & outcomes

The two conditions that define AHVI's cohort are the two conditions we have published outcomes on.

16,004 of AHVI's 17,049 in-scope patients carry a hypertension diagnosis and 5,038 carry a heart failure diagnosis. Both programs below ran on CoachCare with cardiology groups, and one of them is already on the customer list above.

Hypertension

Cardiac Solutions

Cardiology group · RPM · published April 2026

29.1 mmHg Average blood pressure reduction in Stage 2 hypertension patients, the highest risk group in the cohort.

2,738patients monitored

94.8%of Stage 2 patients improved

6.42 mmHgaverage reduction, full cohort

For AHVI: hypertension covers 94% of the in-scope cohort. Documented, device captured blood pressure over time is also the evidence base a renal denervation referral needs.

Observational analysis of 2,738 Cardiac Solutions RPM patients enrolled 12 months or longer. Blood pressure measured baseline to final reading.

Open the Cardiac Solutions case study →

Heart failure

MercyOne Iowa Heart Center

Cardiovascular provider · advanced HF RPM · published 2026

0% readmissions Across six months in 450 advanced heart failure patients, against an 18% 30-day readmission benchmark on the same panel.

450enrolled from a 9,000+ HF population

81readmissions prevented

26GDMT care gaps closed

For AHVI: same shape as this account, a large HF population with a complex subset enrolled first. The heart failure clinic and the APP team are the natural first pod.

Six-month evaluation of 450 patients, NYHA functional class III–IV, ACC/AHA Stage C or D, on daily blood pressure, heart rate and weight transmission. Four HF-related hospitalizations occurred, a 96% reduction; three patients had an HF-related ER visit.

Open the Iowa Heart case study →

What the Cardiac Solutions data actually proves

The lever is monitoring consistency, not clinician minutes.

Patients who submitted readings consistently improved more than twice as much as low consistency patients. Clinician time on its own did not predict better outcomes. That finding is the argument for the operating model on this page. Staff a care team to keep patients transmitting, hold a ratio that makes regular contact possible, and send physician time only where it changes a decision.

Low reading
consistency

3.54 mmHg

High reading
consistency

8.53 mmHg

Average blood pressure reduction by reading consistency among the 2,738-patient Cardiac Solutions RPM cohort: 3.54 mmHg at low consistency against 8.53 mmHg at high consistency.

Cost avoidance

Advocate Aurora

Health system · chronic disease RPM · first six months

For the finance conversation: fewer admissions is the mechanism, cost avoidance is the accounting. Same result, counted two ways.

$2.4M Cost avoidance in six months, from 201 fewer hospitalizations.

74%fewer hospital admissions
271 → 70

85%fewer hospital days
1,838 → 279

63%fewer ED visits
76 → 28

127 chronic disease patients (heart failure, hypertension, diabetes) active on the program, measured against the same population's utilization in the six months prior to launch. Cost avoidance valued at $12,000 per hospitalization. Delivered on the VitalTech platform, now part of CoachCare.

Open the Advocate Aurora case study →

What stands out in this analysis is the magnitude of improvement among the highest-risk patients. These results demonstrate how structured remote monitoring can create meaningful blood pressure reductions where clinical intervention matters most.
CoachCare Chief Medical Officer

01.5 · Financial performance

Positive in month one, and still positive after everything CoachCare charges for.

The forecast below is built on AHVI's measured 17,049-patient cohort, 50 referring providers and three on-site enrollment specialists, priced at the CY2026 fee schedule in the Anchorage locality. Month one clears implementation and EHR setup and still lands positive.

CoachCare fees · 24 mo $6,205,768

Net to AHVI · 24 mo $4,671,823

$10,877,591 of net reimbursement over 24 months splits into $6,205,768 of CoachCare fees and $4,671,823 retained by AHVI, a 43.0% practice margin.

$10.88M

Net reimbursement, 24 months. RPM $7.73M · PCM $3.14M.

$4.67M

Net to AHVI after all CoachCare fees, including implementation and EHR setup.

43.0%

Practice margin across 24 months. 42.7% in year one, higher in year two.

+$2,389

Net to AHVI in month one. The program is cash-positive from the first billing cycle.

Monthly economics, months 1–24

Net reimbursement, total CoachCare fees, and net retained by AHVI

View as table

Month	Net reimbursement	Fees	Net to AHVI

Enrolled services, months 1–24

Active program enrollments by program (services, not unique patients)

View as table

Month	RPM	PCM

6,566

Unique patients in active remote care at month 24, against 8,220 enrolled services.

446

Hospitalizations avoided across 24 months on the modeled program. The mechanism behind that number is the Iowa Heart and Advocate Aurora evidence in Section 01.4.

168,938

Reimbursable claims generated across 24 months, documented and coded by CoachCare.

Basis: CY2026 Medicare Physician Fee Schedule, non-QPP conversion factor $33.4009, Anchorage MAC locality 02102-01. Period: 24 months from go-live. Denominator: 17,049 AHVI patients carrying a heart failure or hypertension diagnosis, supplied by AHVI. Programs modeled: RPM and PCM. Enrolled services (8,220 at month 24) count program enrollments; unique patients (6,566) de-duplicate across programs. Full assumptions and sensitivities accompany the Value Analysis workbook.

Next: The Alaska Factor →

02 8:30 – 9:30 AM

The Alaska Factor

Alaska is not a harder version of the Lower 48. It is a different set of constraints, and most of them run in this program's favor. The one that does not is connectivity, and we have measured it.

02.1 · What is actually different here

Four market conditions that do not co-occur anywhere else in the country.

	Most cardiology markets	Southcentral Alaska
Medicare Advantage	A large share of the Medicare panel sits inside MA plans, each with its own coverage rules for remote monitoring.	Penetration runs around 1–3%. Insurers cannot build low cost networks in a high cost state, so almost no individual MA plans exist. The panel is close to 99% traditional fee for service, and every RPM and PCM code bills across essentially all of it.
Reimbursement locality	Rates track the national conversion factor with typical GPCI adjustment.	Anchorage MAC locality 02102-01 is one of the highest reimbursement Part B localities in the country. The same clinical minute is worth more here.
Model exposure	Hospital bundled payment programs usually arrive first, and the health system absorbs the risk.	No Alaska CBSA falls inside the 188 TEAM markets, so accountability arrives through the cardiology door instead. 15 AHVI cardiologist NPIs appear on the preliminary ASM heart failure list, and there is no hospital program to absorb any of it.
Distance to the clinic	Patients drive in. A missed visit gets rescheduled the same month.	AHVI already travels to the patient, with clinics inside Central Peninsula Hospital in Soldotna and South Peninsula Hospital in Homer, a Mat-Su office, and a monthly rural echo clinic. A missed visit can mean a season.

Put together: a panel with almost no payer fragmentation, priced at one of the highest localities in the country, carrying downside risk with no hospital partner to share it, spread across a geography where continuity is the hardest thing to buy. Remote care answers all four with the same infrastructure.

02.2 · The on-site enrollment specialist

Enrollment is the constraint on this program. Not the population.

Three CoachCare enrollment specialists sit inside AHVI clinics and enroll patients face to face at the point of care. Each carries roughly 80 patients a month, so the on-site engine adds about 240 patients a month. Their salaries are a CoachCare expense and never net against AHVI's margin.

The reason that matters more than it sounds: telephonic outreach converts at roughly 8%. Whether a remote care program reaches census is mostly decided by whether somebody is standing in the clinic when the physician says the word.

On-site specialists, CoachCare employed and funded. They work in AHVI clinics and report into the CoachCare program team.

240

Patients a month of on-site enrollment capacity, at roughly 80 per specialist.

Telephonic conversion rate, which is what the program falls back to without people in the building.

24-month net reimbursement against patients in scope

Everything else held at plan: 50 referring providers, three on-site specialists, same acceptance and conversion rates

View as table

Patients in scope	24-month net reimbursement	Regime

The curve flattens right around AHVI's measured cohort. Above roughly 17,000 patients in scope, adding population barely moves the 24-month number, because the enrollment engine sets the pace long before the population runs out. Below it, every 2,000 patients is worth about half a million dollars of 24-month reimbursement, because the program starts bumping the ceiling instead.

Two consequences. Adding a fourth enrollment specialist pulls revenue forward more than finding more patients does. And the forecast does not depend on an optimistic population estimate, which is usually where these models break.

02.3 · Hiring the Alaska care team

CoachCare carries the headcount. AHVI has a say in who is in the building.

CoachCare runs

Sourcing, screening, employment and payroll for the care team and the on-site specialists
Clinical training, protocol onboarding and ongoing supervision
Coverage when someone leaves, so a vacancy is not AHVI's problem to solve

AHVI participates in

Final selection for the on-site specialists who sit in AHVI clinics every day
Protocol and escalation preferences the pod is trained against
Local hiring preference, so the team knows the communities it is calling

The specifics of the joint selection process are worth agreeing on in this session rather than after signature, because the on-site roles are the ones AHVI staff will work beside daily.

02.4 · The Bush

We audited coverage before we made a claim about it.

CoachCare compiled community level cellular data across 22 Alaska Bush communities, covering the Northwest Arctic, the YK Delta and the North Slope. The finding that matters is not the one people expect.

10 of 22

audited Bush communities have zero 4G LTE coverage and run entirely on 2G and 3G infrastructure

100%

indoor home signal coverage in several of those same communities, including Selawik, Point Hope and Mountain Village

readings cached on the device when there is no signal at all, flushed automatically when one returns

Why a 4G gap is not a coverage gap

Point Lay, Toksook Bay, Hooper Bay and Togiak all report 0% active 4G. They also report reliable 2G and 3G service and strong indoor home coverage. The monitors run on LTE-M and legacy bands, so the absence of 4G does not take a patient off the program. It changes which kit they get.

What the device actually needs

The SIM is embedded in a battery powered monitor. No wall outlet, no router, no Bluetooth pairing, no wifi password. The patient wraps the cuff and presses one button, and the reading goes out the next time the device sees a tower. GCI is the foundational carrier across all 22 communities, and the device hops to AT&T or Verizon when GCI drops in a hub like Bethel or Nome.

Three geographies, three kits

At enrollment the patient's village is checked against a coverage matrix and the kit configures itself.

Tier 1

Road system

Geography: Anchorage bowl, Mat-Su, Kenai Peninsula, Fairbanks, Juneau and the highway corridors. About 75% of the state population.
Connectivity: Standard cellular kit. Dense LTE and 5G, no special handling.

Tier 2

Regional hubs

Geography: Bethel, Nome, Kotzebue, Utqiaġvik, Dillingham, Sitka, Ketchikan, King Salmon, Unalakleet.
Connectivity: GCI LTE native. Cellular kit with wifi fallback.

Tier 3

Bush villages

Geography: Roughly 200 roadless villages, served from the regional hubs by bush carriers. Delivery mechanics are in Section 03.
Connectivity: Cellular where covered. Store and forward where not, with a clinic based backstop.

Where the village clinic comes in

Alaska already has the last mile that everywhere else is missing.

Community health aides work in village clinics across the tribal health network, and they are the people patients already trust with a blood pressure cuff. CoachCare's plan is to use those clinics as activation points, so a Tier 3 patient has somewhere local to confirm delivery, get set up and troubleshoot. Working relationships with the tribal health organizations are in development and not in place today. In development

Two things are honestly still open. Alaska 3PL and bush carrier partnerships are in selection rather than signed, and the village level coverage matrix has to be rebuilt against AHVI's actual patient geography rather than the 22 community sample. Both land in Section 03. In selection

Next: Operational Readiness →

03 9:30 – 11:00 AM

Operational Readiness

A remote care program in Alaska is only as good as the box that arrives at a village post office box in February. This is the machinery behind that box: how the device talks, what hardware a patient gets, how it travels, and what happens when it breaks.

03.1 · How the device stays connected

Three layers of network, then a buffer for when all three are gone.

The SIM sits inside the monitor. There is no hub to plug in, no router to configure, no phone to pair, and no wifi password to type. A patient wraps the cuff and presses one button, and the reading leaves the device the next time it sees a tower.

A reading leaves the monitor over cellular, routes through GCI or a fallback carrier, reaches the CoachCare care team and lands in the athenahealth chart. With no signal the monitor holds up to 60 readings locally and flushes the batch automatically once coverage returns.

Network core

The connectivity core handshakes dynamically across 453 worldwide networks and roams natively on GCI, the dominant carrier in Alaska and the foundational carrier across all 22 audited Bush communities.

Fallback and hopping

A second wireless backbone connects to 4G LTE-M bands wherever local infrastructure exists, including AT&T and Verizon Alaska. If GCI goes down in a hub like Bethel or Nome, the device searches and shifts on its own.

Off-grid patients

For a dry cabin with no service at all, the monitor is battery powered and portable. The patient takes readings at home, carries the device to the village center or clinic, and the cached batch uploads on arrival.

03.2 · The hardware

Three kit configurations, selected by what the patient needs and what their village has.

Standalone cellular BP

The off-grid default

Built-in SIM with memory caching, for single-vital patients anywhere coverage is thin or absent. This is the kit that makes travel-to-sync work.

Tenovi cellular hub

Multi-device patients

For patients on more than one vital, such as blood pressure plus pulse oximetry, who live where home reception is reliable.

Transtek scale

The heart failure addition

Daily weight tracking for fluid retention. This is a protocol requirement on congestive heart failure patients, not an option.

03.3 · Fulfillment

Stop treating Alaska shipments like Lower 48 parcels.

Today devices ship from fulfillment centers in Chattanooga and San Diego. For far-north addresses that adds transit time at every leg and puts battery powered medical hardware into lanes that were never designed for it. The fix is an Anchorage staging node.

Direct to clinic

Pre-configured inventory bulk shipped to AHVI Anchorage offices, so a patient seen in clinic can walk out with a device instead of waiting on a parcel.

Anchorage staging

In-state kitting, serialization and climate-controlled storage, with reverse logistics handled locally rather than routed back to the mainland.

Local exchange

Next-day device replacement inside the road system, which is what keeps a compliance gap from becoming a lost patient.

Partner selection In selection

Three Anchorage partners are under evaluation. Carlile is the leading candidate as the primary staging anchor, with a statewide distribution warehouse, full warehouse management, and a purpose-built network spanning Fairbanks, Kenai and Prudhoe Bay. Royal Alaskan Movers is a flexible mid-size option well suited to kit assembly. Door One Logistics offers FDA-compliant climate-controlled storage and same or next-day delivery to the major metros. The recommended structure is a two-partner system: Carlile for staging, a specialized local courier for high-touch final mile in the Anchorage bowl. Nothing here is signed yet.

Warehouse management and API integration. A webhook connection that turns an enrollment into a 3PL order without anyone rekeying it.
Lot and serial tracking. Continuous device accountability, which matters for both recalls and reconciliation.
Climate-controlled storage. Battery powered monitors cannot sit in unheated 20°F warehousing.
Priority postal injection. A demonstrated path around congested standard postal lanes.
Reverse logistics. Returns, diagnostics, sanitization and refurbishment handled in state.

03.4 · The bush air network

Getting to a roadless village is a two-stage flight, and it is a solved problem.

Jet carriers fly mainline cargo from Anchorage or Fairbanks into roughly two dozen regional hub airports. From there small aircraft, mostly Cessna Caravans and CASA 212s, fan out to gravel village strips, with the USPS Bypass Mail program keeping the frequency up. Alaska runs this network every day for groceries and fuel. Medical devices ride the same lanes.

Postal first

USPS Priority Mail carries flat pricing with no remote surcharges and delivers directly to village post office boxes.

Built for the cold

Packaging configured for extreme sub-zero transit and for declared lithium battery handling rules.

Urgent replacements

Alaska Airlines GoldStreak to the hub plus a village agent gets a replacement device close to same-day.

Set at enrollment

Transit expectations of 3 to 10 business days are told to the patient when they enroll, not discovered later.

Carrier matrix

Carrier	Base and hubs	Role
Ryan Air	8 hubs, 70 villages	Largest Western Alaska bush freight carrier. Handles UPS interlines.
Everts Air Cargo	Fairbanks, 13 hubs	Mainline cargo lift, hazmat certified for lithium battery shipments.
Grant Aviation	YK Delta, Bristol Bay	Major rural bypass and mail carrier on the core medical routes.
Bering Air	Nome, Kotzebue, Unalakleet	Northwest Arctic coverage into the coastal communities.
Wright Air	Fairbanks, Yukon Basin	Grand Caravan fleet reaching remote Interior locations.
Alaska Airlines	Anchorage, jet hubs	GoldStreak same-day and next-flight cargo for urgent replacements.

Lane quotes from these carriers are being obtained rather than contracted. If USPS Bypass Mail policy changes, the fallback is direct-to-carrier freight, which removes the postal dependency entirely. In selection

03.5 · Activation, replacement and who pays for it

A device that arrives and never gets switched on is worse than no device.

The unclaimed parcel problem

In Bush communities a package sits in a post office box until somebody checks it. Every Tier 3 shipment triggers proactive tracking, and the patient gets a call when the kit reaches their regional hub so they know to go collect it. That single step is what keeps devices from going missing between the hub and the kitchen table.

The village clinic In development

Community health aides in village clinics across the tribal health network are the natural activation point: delivery confirmation, hands-on setup and first-line troubleshooting, from someone the patient already knows. Working relationships with the tribal health organizations are being built and are not in place today.

3–5×

What Tier 3 outbound shipping costs against a road system delivery.

Of that cost reaching AHVI. Devices, shipping, replacement and connectivity are CoachCare expenses and never net against practice margin.

Bush communities in the coverage audit so far. The matrix gets rebuilt against AHVI's actual patient geography and refreshed quarterly.

The cost asymmetry is the useful part of this. Serving a patient in Toksook Bay costs several times more to reach than a patient in Anchorage, and that difference sits entirely on the CoachCare side of the agreement. The reimbursement is identical. Nothing in the economics discourages AHVI from enrolling the patients who are hardest to reach, which are usually the patients with the most to gain.

Basis: connectivity and logistics figures come from CoachCare's Alaska operational review, August 2026, covering 22 Bush communities across the Northwest Arctic, YK Delta and North Slope. Coverage percentages are community level and were current at the time of the audit. Capabilities marked in selection or in development are not contracted as of this session.

Next: Clinical Rollout →

04 11:00 AM – 12:00 PM

Clinical Rollout & Day to Day

Section 01 showed the shape of the filter. This is the filter itself: the written thresholds, the decision rules, the emergency pathway and the discharge criteria that AHVI initials section by section before go-live.

04.1 · The escalation engine

The default is not to escalate.

Every monitoring program routes through one shared decision engine. An out-of-range reading is the beginning of the work, not the end of it. The care manager calls the patient, asks the symptom questions for that vital, checks measurement technique and requests a repeat. Most of the time the repeat is fine and the patient has no symptoms, and that is where it stops.

Which means the clinic hears about the readings that survived a human check, not the readings that were out of range.

Any critical valueRegardless of symptoms, and regardless of what the repeat shows.

→

Escalate

Out-of-range trendThree consecutive readings at least an hour apart for blood pressure. Three readings within seven days for heart rate.

→

Escalate

Out of range, repeat back in range, but symptoms presentThe number resolved. The patient did not.

→

Escalate

Out of range, repeat still out of range, no symptomsEscalated to the practice, with a parameter adjustment considered.

→

Escalate

Out of range, repeat back in range, no symptomsDocumented in full and closed by the care manager. This is the majority case, and it is the one that never reaches an AHVI clinician.

→

Document and stop

If the patient does not answer

The care manager leaves a voicemail with a callback number and instructions to seek care if things worsen. If a critical value or an out-of-range trend exists, the escalation goes to the practice anyway. A missed call never suppresses an escalation.

Escalation cadence

Outreach on an out-of-range trend runs weekly. Escalations for trends without symptoms are batched biweekly per patient, and each one carries up to five recent vitals so the reviewing clinician sees the trajectory rather than a single number.

How it reaches you

AHVI picks the channel: EHR task, secure message, phone, fax or email. The preference is recorded in the SOP and applies to every escalation except the emergency pathway, which overrides it.

04.2 · The thresholds AHVI is signing off on

Written numbers, not vendor discretion.

These are the cardiology-relevant defaults. AHVI can tighten or loosen any of them per patient or across the panel, and any change is documented against the patient record.

Vital	Normal range	Out-of-range trend	Critical
Blood pressure	90–120 systolic 60–80 diastolic	≥160 or ≤90 systolic ≥110 or ≤40 diastolic	≥170 or ≤80 systolic ≥100 or ≤40 diastolic
Heart rate	60–100 bpm	≥120 or ≤50 bpm	≥130 or ≤40 bpm
Weight	Baseline	Evaluated urgently in heart failure, edema and chronic kidney disease	Gain ≥3 lb in a day or ≥5 lb in a week Unexplained loss ≥15 lb in a month
Pulse oximetry	95–100%	≤92% without home oxygen ≤90% with home oxygen	≤90%

Critical weight change escalates with or without symptoms, which is the threshold that does the most work in a heart failure panel.

04.3 · The emergency pathway

On active emergent symptoms, CoachCare calls 911 with the patient still on the line.

This is the one place where CoachCare policy overrides AHVI preference. Whatever escalation channel AHVI selects for everything else, an active emergency does not wait for it.

Active emergent symptoms reported during outreachChest pain, pressure, heaviness or tightness. Jaw, neck, arm or mid-back pain. New or sudden shortness of breath. Confusion, slurred speech, one-sided numbness or weakness. Vision loss. Syncope or near-syncope. Worst headache of their life. Throat, tongue or lip swelling.

→

Call 911, then notify clinic

Patient refuses 911CoachCare calls AHVI with the patient still on the line. If AHVI is not reachable, CoachCare activates emergency services anyway.

→

Clinic, then 911

Recent but not active symptoms, within 72 hoursThe same symptom list, reported after the fact rather than in the moment.

→

Escalate to clinic

Say this part out loud

This is not a 24/7 monitoring service, and the patient consents to that in writing.

Readings and responses are reviewed Monday to Friday, 8:00 AM to 5:00 PM in the patient's local time, with published holidays off. Patients are told at consent that the service is for trend monitoring and non-emergent coordination, that they must call 911 or go to the ER for emergencies, and that they use AHVI's on-call service or urgent care after hours. Setting that expectation correctly in the room today is worth more than any capability claim, because a cardiologist who thinks this is overnight telemetry will be disappointed on the first weekend.

04.4 · Hypertension and heart failure, day to day

What the patient does, and what the care manager does with it.

Hypertension

Twice daily, after medications

A cellular blood pressure monitor, read in the morning and evening after meds. Where a patient cannot manage twice, once daily is the floor. Blood pressure and heart rate thresholds both apply.

Heart failure

Blood pressure plus a daily weight

Same blood pressure protocol, with a connected scale read once daily at the same time in the same clothing, preferably in the morning after voiding. Weight is the early signal, which is why the critical thresholds on it are tight.

The care manager screens for worsening shortness of breath, abdominal bloating, increased lower extremity edema, chest heaviness, palpitations, a new or worsening cough, and any change in how many pillows the patient needs at night.

Adherence

Reminders go out by text, email or phone. A device that stops transmitting triggers an offline alert at around 50 hours, and the care team troubleshoots before non-reporting becomes a clinical blind spot. Persistent non-reporting escalates when it is clinically relevant.

Care management time

Principal Care Management runs a minimum of 30 minutes per patient per month, though chart review and coordination typically push actual time to 45 or 60. Every patient gets a care plan per monitored condition, reviewed at least annually and available to the patient and their caregivers at any time.

04.5 · Post-discharge

An ER visit or admission in the last 60 days triggers a fixed three-touch sequence.

This is the mechanism behind the procedural throughput argument in Section 01. A TAVR, CABG or PCI discharge lands in the same sequence, and the cadence is designed around the window where readmissions actually happen.

Day 1 to 2

Initial contact

Identify what precipitated the event, from medication lapses to diet, falls or acute illness
Reconcile medications against the discharge summary, including anything new, adjusted or stopped
Confirm a follow-up appointment is booked within 7 to 14 days
Screen for disease-specific symptoms and address immediate barriers to care

Day 5 to 8

Secondary follow-up

Verify the patient is actually taking the new regimen
Re-evaluate the triggers identified on the first call
Confirm the office visit happened or is still on the calendar
Check that ordered blood work was completed

Day 12 to 14

Tertiary follow-up

Continued medication adherence and trigger review
Review the outcome of completed provider visits against the care plan
Final symptom assessment for the episode

Every touch documents the encounter and escalates any clinical alert through the same engine in 04.1.

04.6 · From patient 1 to patient 6,566

The care team grows with the census. AHVI's headcount does not move.

CoachCare staffs at roughly 160 patients per care team member against an industry average nearer 300. Applied to the modeled enrollment curve, that is what the team looks like at each stage of the ramp.

Stage	Unique patients	Enrolled services	CoachCare care team at 160:1
Month 3	434	548	~3
Month 12	2,786	3,519	~17
Month 24	6,566	8,220	~41

The thing worth noticing is that the escalation logic in 04.1 does not change between month 3 and month 24. The same thresholds, the same repeat-and-symptom check, the same channel. What scales is the number of people running it, and that is a CoachCare hiring problem rather than an AHVI one.

Discharge is governed too

A patient can be discharged on an AHVI order, on revoked consent, on death, or on admission to hospice or long-term care. Beyond that, non-compliance for 90 days triggers a notice to AHVI and another 90 days of monitoring before discharge at 180. AHVI is notified in every case, and CoachCare escalates a recommended discharge for approval rather than acting alone.

What AHVI owns

Provider orders and medical necessity, timely response to escalations, and all medical decision-making including medication changes. CoachCare notifies on out-of-range labs but does not interpret them for the patient. The line between coordination and clinical judgment is drawn explicitly in the SOP.

Basis: escalation logic, thresholds, protocols and discharge criteria are from the CoachCare Care Management Programs Standard Operating Procedures, version March 2026, which AHVI initials by section and attests to before go-live. Census figures are the modeled AHVI enrollment curve over 24 months from go-live. Unique patients de-duplicate across programs; enrolled services count program enrollments. Care team size is derived from the 160:1 staffing ratio applied to modeled unique patients.

Next: Integration →

05 1:00 – 1:45 PM

Integration

A remote care program that lives in its own portal is a program AHVI physicians will stop opening by week six. Everything below happens inside athenahealth, in the chart the provider already has open.

05.1 · Why the loop has to close

Five handoffs. A one-way feed leaves four of them on somebody's desk.

A read-only vitals feed is the version most vendors ship. It solves one of these five steps and quietly hands the other four back to AHVI staff as monthly manual work: chasing the order, retyping the escalation, filing the documentation, and creating a claim per patient per month.

The closed loop: an order signed in athenaOne starts the program, device vitals return as discrete values in the Vitals tab, escalations open a Patient Case, monthly Evidence of Care documents file to Clinical Documents, and charges post to Billing by the fifth business day of the following month. Enrollment status stays visible in the existing clinical workflow throughout.

Integration points, not one. Bi-directional enrollment by service, health history exchange, discrete vitals, escalation tasks, compliance documentation and automated claim generation.

Days from signed order to a patient receiving services. The enrollment flag and the order trigger the program without a separate intake.

Manual claims created per patient per month. The CoachCare billing engine generates them and posts them into athenahealth.

05.2 · Where everything lands

The navigation paths AHVI staff will actually use.

What	Where it lands in athenaOne	Cadence
Enrollment order	Clinical › Chart › Create Order Group, then search the referral order and sign. Device selection goes in the Note to Provider field.	Per patient, once
Device vitals	The Vitals tab, posted by the CoachCare service account as discrete values. On athenaPractice they route to a flowsheet configured per practice.	Continuous
Escalations	Notes from the CoachCare platform arrive as a Patient Case, which routes and tracks like any other case rather than sitting in an inbox.	As triggered
Evidence of Care	Clinicals › Chart › Find › Clinical Document. This is the compliance record behind every billed month.	Monthly
Charges	Billing › View Claim History, carrying CPT code, unit count, diagnosis codes and date of service.	By the 5th business day

Orders and the receiving account still carry the legacy MD Revolution label inside athenahealth. That is an in-product naming artifact, not a separate system.

05.3 · The codes that post themselves

Every code in AHVI's modeled program flows through the integration.

Code	What it covers	Program
99453	Device setup and patient education, billed once per provider per patient	RPM
99454	Device supply and data transmission, 16 or more days of data in 30	RPM
99445	Device supply and transmission at 2 to 15 days of data, new for 2026 and not cumulative with 99454	RPM
99457	First 20 minutes of clinical time, including at least one live two-way interaction	RPM
99470	First 10 to 19 minutes of clinical time, new for 2026 and not cumulative with 99457	RPM
99458	Each additional 20 minutes beyond the first	RPM
99427	First 30 minutes of principal care management per month	PCM
99426	Each additional 30 minutes per month	PCM

The two 2026 additions matter for a ramping program. 99445 and 99470 capture partial months that used to bill nothing, which is most of a patient's first month. One exception to flag: G0506, the in-office enrollment code, has to be captured by the provider in the room and does not pass through the integration.

05.4 · athenaPractice today, athenaOne next

Both integrations are already built. The migration is configuration, not a rebuild.

AHVI runs athenaPractice today and is moving to athenaOne. CoachCare has documented, working integrations on both, which means the program can start now on athenaPractice and follow AHVI across, or wait and stand up native on athenaOne. That choice is AHVI's and it is worth making in this session, because it changes the implementation sequence.

athenaPractice setup

Signature privileges on the care management document types
Enroll and disenroll orders created for each program
Statement of medical necessity added as a template or on-demand text
Enrollment observation terms on the patient banner, flowsheet and custom forms
Procedure codes built, and a Direct messaging address configured

athenaOne setup

Two custom demographic fields for RPM status and status detail, with enrolled, opt-out and disenrolled values
A remote care management order set, scoped to all users and specialties
CoachCare set as the referral receiver on that order set
Consent, provider order and necessity language stored in the order's internal note
Procedure codes added to the fee schedule

The honest version

This is a short configuration checklist on AHVI's side, not zero work.

The integration itself does not get rebuilt. What gets redone is the athenaOne side of the setup above: custom fields, an order set, and procedure codes on the fee schedule. CoachCare runs the build and AHVI approves it. Calling that zero lift would be overselling it, and the IT leadership in this room would spot that immediately. Calling it a half-day of configuration is closer to true.

One claim worth testing in diligence rather than taking on faith: CoachCare's published position is that it is the only care management partner integrated with athenahealth that generates claims automatically through its own billing engine. Ask any competing vendor to describe their monthly claim process and see whether a person has to create each claim.

05.5 · The patient app

Useful to the patient. Never required for the program to work.

What the patient gets

The care plan for every monitored condition, available to the patient and their caregivers at any time, in the app, on the platform or in written form. Alongside it sits their reading history, education material in their preferred format, and a route back to the care team between visits.

What it is not

The app is not a transmission dependency. Devices carry their own cellular connection and push readings without a phone, an app login or a Bluetooth pairing step. A patient in a village with no smartphone is on exactly the same program as a patient in Anchorage with a new iPhone.

That separation is the reason the Alaska geography in Section 02 works. Vendors who route vitals through a patient's phone inherit every problem with that patient's phone, and in the Bush that is most of the panel.

Basis: workflows, navigation paths and setup steps are from the CoachCare closed loop integration documentation for athenaPractice and athenaOne, 2026, and the CoachCare athenahealth integration overview. CPT codes reflect the CY2026 Physician Fee Schedule, including 99445 and 99470 effective 1 January 2026. Programs shown are those modeled for AHVI. Implementation sequence and the athenaOne cutover timing are subject to AHVI's own migration schedule.

Next: Next Steps →

06 1:45 – 2:30 PM

Next Steps

Three decisions belong to AHVI and can be made in this room. Four items belong to CoachCare and are still open. Everything else is scheduling.

06.1 · Financial review

One input moves this forecast. The rest is arithmetic.

The 24-month model produces $10,877,591 of net reimbursement, $6,205,768 of CoachCare fees and $4,671,823 retained by AHVI at a 43.0% margin, positive from month one. Every one of those figures rests on the 17,049-patient cohort AHVI supplied, and there are four questions about that number worth settling before anyone signs anything.

Question for finance	Why it matters
Is the 17,049 Medicare only, or all payer?	The model applies no payer haircut. If the count includes commercial and Medicaid patients, the billable cohort is smaller than modeled. A 65% Medicare read would put 24-month reimbursement nearer $9.8M instead of $10.9M.
What lookback produced it?	Active patients over 12, 18 or 24 months are three different cohorts. The enrollment ramp assumes these patients are reachable and currently in the practice.
Why is it 38% of the Medicare panel?	17,049 against a 45,246 total Medicare panel is low for a cardiology book. Either the panel figure is inflated or the query was narrower than every patient with a heart failure or hypertension diagnosis. Worth reconciling in the same conversation.
Are there 50 referring providers?	Referral volume is the top of the enrollment funnel. Against roughly 28 cardiologists and 31 advanced practice providers, 50 is the assumption the ramp is built on.

The useful news from Section 02 is that the answers change the number less than people expect. The forecast sits on the flat part of the population curve, so anything at or above roughly 17,000 in scope produces nearly the same 24-month result. Below that it starts falling in a straight line, which is why the payer question is the one to close first.

06.2 · Contract review

Two documents, and one date that governs a clause in both.

The commercial agreement

Program scope, which for the modeled forecast is RPM and PCM. Fee structure, term, and the three CoachCare-funded on-site enrollment specialists. AHVI bills under its own NPIs and holds the payer relationship throughout.

The Standard Operating Procedures

The clinical document from Section 04, initialed section by section with a final attestation and signature block. It fixes the thresholds, the escalation logic, the emergency pathway and the discharge criteria in writing, and it records AHVI's preferred escalation channel.

The date that governs both

15 AHVI cardiologist NPIs appear on the preliminary CMS Ambulatory Specialty Model participant list for the heart failure cohort, published February 2026 against roughly 2024 claims. CMS is expected to publish the final list in summer 2026, and four of the fifteen are no longer on AHVI's roster, which is consistent with a historical-claims preliminary file. Any ASM language in the contract should be drafted against the final list rather than this one. That is a scheduling constraint on one clause, not on the agreement.

06.3 · Rollout sequence

Dependency ordered rather than date stamped, because the go-live date is AHVI's to set.

This is a proposal for discussion in this session, not a committed schedule. The sequence matters more than the dates: two workstreams run in parallel, and only one of them has a long lead time.

Today

Decisions and signatures

Agree the three decisions below, settle the payer question with finance, and start contract and SOP review. Nothing downstream can be scheduled until the athenahealth path is chosen.

AHVI and CoachCare

Workstream A · starts immediately

Recruit the Alaska care team

This is the long pole. Sourcing, screening and onboarding three on-site enrollment specialists plus the initial care team pod takes longer than any technical step, and the enrollment engine sets the pace of the entire forecast. AHVI participates in final selection for the on-site roles.

CoachCare leads, AHVI selects

Workstream B · in parallel

EHR build and SOP execution

Custom demographic fields, the referral order set, the receiver record and procedure codes on the fee schedule. CoachCare runs the build and AHVI approves it. Roughly a half day of configuration on AHVI's side, as covered in Section 05.

CoachCare builds, AHVI approves

Before first enrollment

Alaska logistics locked

Rebuild the village-level coverage matrix against AHVI's actual patient geography rather than the 22-community sample, select the Anchorage 3PL, and stage pre-configured device inventory in state and at the Anchorage clinics.

CoachCare

Go-live

First cohort

Specialists enroll at the point of care and patients begin receiving services within five days of a signed order. Month one clears implementation and EHR setup and still nets positive to AHVI. The ramp from there is the curve in Section 01.

Joint

06.4 · The ask

Three decisions, and they can all be made today.

athenaPractice now, or athenaOne native?

Start on athenaPractice and migrate the program alongside AHVI's own cutover, or wait and stand the program up native on athenaOne. Both integrations exist. Neither is wrong.

Unblocks: the implementation sequence and the go-live date

What is the payer scope of the 17,049?

Medicare only or all payer, and over what lookback. This is the only input that meaningfully moves the 24-month forecast, and AHVI is the only party who can answer it.

Unblocks: a final financial model AHVI can underwrite

What is the target go-live date?

Care team recruiting is the long lead item and everything else fits around it. A date set today sets the hiring start, the device staging window and the first enrollment cohort.

Unblocks: recruiting, logistics and inventory

What CoachCare still owes AHVI

Four things are genuinely open on our side.

Re-verify the ASM participant listRe-query the CMS dataset when the final CY2027 list publishes and confirm which AHVI NPIs carry forward.
When CMS publishes
Rebuild the coverage matrix to AHVI's geographyThe 22-community audit proves the method. It is not yet mapped to where AHVI's patients actually live.
Before first enrollment
Complete Alaska logistics selectionAnchorage 3PL contracted and bush carrier lane quotes converted into committed transit commitments.
Before first enrollment
Build the tribal health activation relationshipsVillage clinic and community health aide activation for Tier 3 patients is a plan today, not a working channel.
Ahead of Bush enrollment

AHVI has a measured population, the highest reimbursement locality in the country, and downside risk arriving in CY2027 with no hospital partner to absorb it. The program that answers all three is the same program, and it pays for itself from the first month.

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