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CareTrack CareTrack provides a Telecare practice extension for out-of-office care monitoring and coordination

The screening reminder that works is usually a phone call.October is Breast Cancer Awareness Month, and October 16 is Na...
10/15/2026

The screening reminder that works is usually a phone call.

October is Breast Cancer Awareness Month, and October 16 is National Mammography Day. Most practices already know which of their patients are overdue for a mammogram. Knowing is rarely the gap. Reaching is.

A care gap report tells a practice that a patient is due. It does not tell the practice that she has no transportation on weekdays, or that she has been meaning to schedule for eight months, or that she is not certain what her plan covers. Those are the reasons screenings do not happen, and none of them resolve on their own.

This is one of the quieter benefits of running a care management program. When a coordinator is already speaking with a patient every month about her blood pressure, the screening conversation has somewhere to live. It is not a reminder postcard from an office she has not visited in a year. It is someone she has talked to before, asking whether she has scheduled it yet and helping her work out what is in the way.

Preventive care works when somebody follows up. That holds for mammograms, colonoscopies, diabetic eye exams and every other measure a practice gets scored on at the end of the year.

How does your practice handle follow up when a patient is overdue for a screening?

Chronic Care Management: https://bit.ly/4hbCu0M

Software can flag a number. It takes a person to call and ask why.National Case Management Week runs October 11 through ...
10/13/2026

Software can flag a number. It takes a person to call and ask why.

National Case Management Week runs October 11 through 17, which is a reasonable moment to describe what our care coordinators actually do all day.

They call the patient who has not sent a reading in four days. They notice that a blood pressure trend has drifted over three weeks rather than spiked in one afternoon. They find out that a prescription was never filled because the pharmacy changed hands. They ask how things are going at home, and they write down what they hear in the physician's chart so the care team sees it before the next visit rather than after.

None of that is automated. Software can flag a number. It takes a person to call and ask why.

The physicians we work with set the protocols and make the clinical decisions. Our coordinators handle the consistent, unglamorous follow through in between, which is where care management programs either work or quietly fall apart.

To every case manager, care coordinator and nurse navigator doing this work, in our building and everywhere else: thank you.

No reflection question here. Close on the thank you and let the comments be what they will be. If you want a prompt, use a light one: if you work in case management, tell us what people most often get wrong about the job.

Careers at CareTrack: https://bit.ly/47hvo5a

West Georgia Internal Medicine launched its CareTrack program in June 2026, and the early results are already encouragin...
10/08/2026

West Georgia Internal Medicine launched its CareTrack program in June 2026, and the early results are already encouraging.

Among patients whose average systolic blood pressure was above 140 during their first 45 days of monitoring, 72% improved over the following 45 days, and 32% moved to an average systolic blood pressure below 140. Clinical alert frequency also declined significantly over that same period.

And the longer patients stay engaged, the better the trend is beginning to look.

Early results like these start with something that can be easy to overlook: getting both physicians and patients engaged in the program.

Cindy Barge, Practice Administrator at West Georgia Internal Medicine, shared what they’re seeing:

“Our physicians are really on board to make referrals, and they have had positive feedback from all of our patients.”

That buy-in matters. Remote Patient Monitoring only becomes meaningful when patients participate, physicians trust the program, and the information collected between visits becomes part of an ongoing care workflow.

CareTrack supports the work behind that process—from patient outreach and enrollment to monitoring, follow-up and documentation—while West Georgia Internal Medicine’s physicians remain at the center of clinical decision-making.

WGIM is still early in its program, but the first few months are showing what can happen when strong physician participation, patient engagement and consistent between-visit support come together.

We’re looking forward to seeing where the trend goes from here!

Explore CareTrack results and case studies: https://bit.ly/4AS2gPw

The care management program for the patient with one serious condition.Most care management conversations assume a patie...
10/06/2026

The care management program for the patient with one serious condition.

Most care management conversations assume a patient with several chronic conditions. Chronic Care Management is built that way. It requires two or more.

Plenty of Medicare patients do not fit that description. A patient recovering from a heart failure exacerbation. A patient whose COPD has become difficult to control. One condition, serious enough to need attention every month, and no second condition to qualify them for CCM. Those patients often land in no program at all, which means no structured follow up between visits at exactly the point they need it most.

Principal Care Management exists for them. PCM covers a single high risk condition expected to last at least three months and requiring ongoing monitoring, medication adjustment or care plan management. It is frequently the right program in the weeks after a hospitalization, when a patient needs close attention on one specific problem rather than broad chronic care.

Our 2026 PCM guide covers the CPT codes, the difference between the physician and clinical staff pathways, and when PCM is the better choice than CCM. It is written for the person who has to actually run the program, not for a brochure.

Does your practice use PCM, or do single condition patients fall through to no program at all?

PCM CPT Codes 2026 guide: https://bit.ly/3TzKMqo

Principal Care Management: https://bit.ly/4yjZwZw

10/01/2026

Rural healthcare does not lack commitment. It lacks connection.

Rural healthcare does not lack commitment. Too often, though, the people, programs and resources already doing the work are not connected to each other.

CareTrack recently sponsored a Rural Health and Alternative Funding Roundtable at Tanner Health System in Carrollton, bringing together healthcare, nonprofit and foundation leaders from across West Georgia for an open conversation about the challenges facing rural communities and what it will take to address them.

The discussion covered changing funding models, transportation barriers, health literacy, patient access, technology and the need for stronger coordination across community resources. One theme kept surfacing: meaningful solutions require connection.

Technology has a role to play. Remote Patient Monitoring, Chronic Care Management and other digital health tools can extend care beyond the office visit and lower the barriers for patients who struggle to reach traditional care. But technology alone is not the answer.

The group was clear on that point. Technology should support human care, not replace it.
That is close to how we think about care at CareTrack. The right technology creates visibility and connection between visits. It is the people behind it, patients, physicians, care teams and community partners, who turn that connection into care.

Thank you to the healthcare and community leaders who joined us and shared their perspectives. We look forward to continuing the conversation and finding new ways to strengthen rural healthcare together.

What is the biggest barrier to care access in the rural communities your organization serves?

Hospitals and health systems: https://bit.ly/4ADUMQd

The prescription can be right. But what happens when the medication runs out?World Heart Day is a good occasion to talk ...
09/29/2026

The prescription can be right. But what happens when the medication runs out?

World Heart Day is a good occasion to talk about one of the less visible challenges in cardiovascular care: what happens when a patient stops taking a prescribed medication.

Sometimes it’s a refill that lapses. A prior authorization stalls. A side effect goes unmentioned. The pharmacy changes. Cost becomes a barrier. Whatever the reason, medication gaps can be difficult to identify between office visits. A medication may still appear on the patient’s chart even when circumstances at home have changed.

One CareTrack patient described what consistent follow-through looked like from their side:

“I'm very thankful for the care and am so relieved to have it! I was down to only a few days left of my medication and was beginning to worry. I was relieved the Care Team worked so quickly to get it for me.”

There’s nothing flashy about that story. It’s a phone call, a pharmacy, and someone whose job it was to notice.

That’s part of the value of Chronic Care Management. CareTrack’s care coordinators stay connected with patients between appointments, supporting medication management, care-plan adherence, referrals, and ongoing communication under the direction of the patient’s practice. What happens is documented in the EHR, while the physician remains in charge of care.

Cardiovascular health is managed largely in the days and weeks patients spend between visits. Sometimes the difference is simply making sure an important question gets asked before a small problem becomes a bigger one.

This World Heart Day, it’s worth remembering that better continuity of care isn’t always complicated. Sometimes, it starts with consistent follow-through.

Chronic Care Management: https://bit.ly/4hbCu0M

There are about fourteen weeks left to improve this year’s Annual Wellness Visit numbers.Late September is when the Q4 m...
09/24/2026

There are about fourteen weeks left to improve this year’s Annual Wellness Visit numbers.

Late September is when the Q4 math starts to become real. Annual Wellness Visits remain underutilized, with many eligible Medicare beneficiaries missing an important opportunity for preventive care.

It’s rarely because practices don’t value prevention. The AWV requires a structured Health Risk Assessment and personalized prevention plan, and fitting that work into an already busy practice takes a reliable workflow.

Across CareTrack partner practices, AWV utilization averages 73%. Much of CareTrack’s approach happens before the appointment: our team identifies eligible patients, handles outreach and scheduling, completes the Health Risk Assessment with patients before the visit, and prepares the information in the EHR so the provider can focus on the patient and prevention planning.

The opportunity extends beyond the visit itself. An AWV can surface preventive-care gaps and identify patients who may benefit from additional care-management support. It may also serve as the initiating visit for Chronic Care Management (CCM) or Advanced Primary Care Management (APCM) when an initiating visit is required and applicable CMS requirements are met.

And when medically necessary, a significant and separately identifiable E/M service may be billed on the same day as an AWV using modifier 25.

The AWV can be more than an annual requirement. With the right workflow, it can become a front door to a more connected approach to care.

Do you know your practice’s AWV completion rate off the top of your head?

Annual Wellness Visits: https://bit.ly/3SxSsZP

2026 AWV billing guide: https://bit.ly/4qYgOsv

Book a demo: https://bit.ly/4fDc1Zt

Falls don't happen in the exam room.Falls Prevention Awareness Week runs September 21–25, landing in the middle of Healt...
09/22/2026

Falls don't happen in the exam room.

Falls Prevention Awareness Week runs September 21–25, landing in the middle of Healthy Aging Month for good reason. For an older adult, a fall is often the event that ends independent living.

Here's what makes falls a care-coordination problem as much as a clinical one: nearly every contributing factor shows up between visits, and most are things a patient wouldn't think to call about.

A new prescription that causes lightheadedness in the first week. A walker left in the garage because using it feels like giving up. Vision that's changed since the last eye exam. Getting up at night more often than last year. A rug, a step, a bathroom without a grab bar.

None of that surfaces in a fifteen-minute visit unless someone asks. It surfaces in conversation — the kind that happens on a monthly care-management call, when a coordinator who knows the patient's history has the time to ask how things are going at home and what's changed since last month.

CareTrack's care coordinators work under protocols each practice defines, and what they learn goes into the physician's chart where it belongs. The clinical judgment stays with the care team. Consistent asking is what we add.

The National Council on Aging has a full toolkit for practices and community organizations marking the week.

If your practice is marking the week, we'd like to hear what's worked!

NCOA Falls Prevention Awareness Week toolkit: https://bit.ly/4yroPIV ·
Chronic Care Management: https://bit.ly/4hbCu0M

This year's World Patient Safety Day is about chronic disease. That makes it a between-visit problem.WHO's theme for Wor...
09/17/2026

This year's World Patient Safety Day is about chronic disease. That makes it a between-visit problem.

WHO's theme for World Patient Safety Day 2026 is safe care for noncommunicable diseases, under the slogan “Safe care for life!”

It's a meaningful choice. Patient safety conversations tend to center on the acute setting — the OR, the med pass, the handoff at shift change. But people living with diabetes, heart failure, COPD, and hypertension receive care over decades, across multiple settings, from clinicians who don't always share a chart. WHO's framing is that risk in chronic disease accumulates across the continuity of care, not in a single moment of it.

Anyone who has run a care-management program recognizes the failure points. A medication changed at discharge that the primary care team never sees. A patient who stops a prescription because of a side effect nobody asked about. Symptoms that develop in week three of a twelve-week gap between appointments. Instructions given at a visit and understood differently at home.

None of those are dramatic events. They're gaps. And they close the same way every time — someone reaches out, asks, documents what they learn, and gets it in front of the physician.

That's the argument for treating care coordination as safety infrastructure rather than an administrative service. The monthly call, the discharge follow-up, the medication review: that work exists to catch things before they become events.

Where does the handoff most often break down in your organization — after discharge, between specialists, or between visits?

WHO campaign page: https://bit.ly/4gOfpzJ

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