Thrive CCM pairs daily remote monitoring with monthly clinical check-ins, in English, Mandarin, and Cantonese — so chronic conditions stay managed between office visits, not after a crisis.
Chronic Care Management and Remote Patient Monitoring are billed separately under Medicare, but at Thrive they work as one program: data comes in daily, a clinician reviews it monthly, and care plans adjust before issues escalate.
For patients with two or more chronic conditions — hypertension, diabetes, COPD, heart failure. A monthly care plan review, medication reconciliation, and a direct line to a clinician between visits.
CCM · 20+ min/monthConnected blood pressure cuffs, pulse oximeters, and scales send daily readings to our care team. Out-of-range values trigger same-day outreach — not a note in a chart no one reads until next visit.
RPM · daily dataMost of our patients speak Mandarin or Cantonese at home. Every check-in, reminder, and care plan is delivered in the language a patient is most comfortable in — by clinicians who speak it too.
中文 · 粵語 · EnglishNo app to figure out, no portal to log into. The monitoring happens quietly in the background of a normal day — the care team does the watching.
Patient uses a connected BP cuff, pulse oximeter, or scale at home — readings transmit automatically, no smartphone required.
Care team monitors incoming data against each patient's individualized thresholds set by their physician.
An out-of-range reading prompts a same-day call in the patient's preferred language — often resolving the issue before it becomes urgent.
A clinician reviews the month's trends, adjusts medications or goals, and documents everything for the patient's primary care physician.
A primary care physician refers a patient, or a patient calls us directly. We confirm Medicare eligibility and two or more qualifying chronic conditions.
A clinician — often the same person who'll review monthly data — walks through the program, sets monitoring goals, and answers questions in the patient's language.
Cellular-connected monitoring devices ship directly to the patient's home, pre-configured. No Wi-Fi setup, no app downloads.
Daily monitoring and monthly reviews continue automatically — most patients hear from us only when there's something worth discussing.
"My nurse called the same afternoon my blood pressure was high. We adjusted my medication that day — I didn't have to wait for my next appointment."
「我血压偏高的那天下午，护士就打电话来了。当天就调整了药物，不用等到下次复诊。」
— Thrive CCM patient, Honolulu, HI
If a patient has Original Medicare or a Medicare Advantage plan and two or more of the conditions below, they likely qualify for CCM — and RPM if their physician orders monitoring.
Daily blood pressure monitoring catches trends weeks before they'd show up at a quarterly visit.
Pulse oximetry monitoring flags early signs of exacerbation, often avoiding an emergency room visit.
Care navigation supports both patients and family caregivers, with materials available in Mandarin and Cantonese.
Monthly reviews track staging and coordinate timing with nephrology referrals.
Diabetes, arthritis, depression, osteoporosis, and other chronic conditions may also qualify — ask during enrollment.
Every patient is assigned to the same small care team each month — not a rotating call center.
Oversees care plans and reviews flagged readings
Reviews incoming vitals and places same-day calls
Handles scheduling, device questions, and family calls
Receives monthly summaries — Thrive complements, not replaces
There's no cost to Medicare patients for CCM and RPM enrollment beyond standard Medicare cost-sharing. Call or message us — we'll confirm eligibility and schedule a welcome visit.