9 Proven Telehealth Solutions
Improving Chronic Disease Management

Chronic disease is the leading cause of death, disability, and healthcare spending in the U.S. — and it disproportionately impacts rural communities. Yet rural patients with diabetes, hypertension, COPD, and heart failure often face delayed treatment, missed follow-ups, and limited access to both primary and specialty care. These gaps contribute to avoidable emergency visits, hospitalizations, and long-term complications that strain rural health systems and impact the people’s and their families’ quality of life.

As the CMS Rural Health Transformation Program (RHTP) challenges states and providers to redesign care delivery, chronic care management emerges as a core area for scalable impact. In continuation of our series on “Proven Telehealth Solutions for Improving Rural Access to Care”, this Telehealth Tuesday highlights six proven telehealth solutions that are already improving access, adherence, and outcomes for patients with chronic conditions — while helping states strengthen their RHTP proposals.

The Role of Telehealth in Chronic Disease Management

The care of chronic diseases is not a single or occasional touchpoint like your annual physical. Chronic Care management requires a continuous cycle of diagnosis, treatment planning, and continuous intervention to prevent a decline in health.

Telehealth supports all three:

• Diagnosis: Virtual visits and e-visits initiate workups and address new symptoms without long wait times or travel.

• Treatment: Providers use video visits and asynchronous tools to adjust medications, educate patients, and revise care plans.

• Intervention: Remote monitoring detects deterioration in real time, triggering escalation before patients end up in the ED.

This flexible set of tools enables rural care providers to build care-at-a-distance models that are proactive, scalable, and cost-effective — especially for high-risk patients in rural settings.

Chronic Care Management (CCM) & Telehealth

Medicare’s Chronic Care Management (CCM) program gives practices a framework — and reimbursement pathway — for delivering coordinated, continuous care between office visits. Patients with two or more chronic conditions qualify, and care teams bill monthly for structured outreach, medication management, and care plan updates.

• Multiple CCM Billing codes ensure financial sustainability.

• Clinical staff (nurses, case managers, care coordinators) handle outreach, education, and care plan updates.

• Physicians and advanced practice providers oversee plans, adjust medications, and make clinical decisions.

CCM for Medicaid patients presents a more complex landscape compared to Medicare, as coverage and reimbursement vary significantly by state. While Medicare offers a standardized national program with defined CPT codes, Medicaid decisions are left to states and often further shaped by managed care organizations. Some states, like California and New York, reimburse for CCM through certain Medicaid managed care plans, while others deliver CCM-like services under case management or Health Home programs. Reimbursement rates are typically lower than Medicare, prior authorizations may be required, and billing codes can differ.

The clinical approach to Medicaid CCM also requires a broader lens. Patients are more likely to face social determinants of health barriers — such as housing instability, transportation challenges, and limited health literacy — on top of complex medical and behavioral health needs. This means care coordinators and nurses often spend more time connecting patients to community resources, addressing behavioral health issues, and managing higher utilization patterns.

For rural providers, sustainability depends on targeting high-utilizer populations, partnering with FQHCs or Medicaid managed care plans, and demonstrating reductions in ED visits and hospitalizations. While more administratively complex, Medicaid CCM offers significant opportunities to improve access and equity when implemented strategically.

CCM by itself improves continuity and coordination — but combined with telehealth services like video visits and RPM, it becomes a powerful, proactive model for rural chronic care.

Chronic Disease DIAGNOSIS with Telehealth

As I highlighted in last week’s article on the use of telehealth to improve access to primary care, the continuity of care — even for annual wellness visits — can be a real game changer in rural communities

While infrequent virtual visits cannot lead to the reliable diagnosis of chronic diseases such as hypertension (unless the patient has and uses a reliable blood pressure cuff) they can unveil a deterioration of quality of life — shortness of breath, dizziness, trouble sleeping — that prompts an in person visit for a more thorough diagnostic workup.

By the way: most in-person visits also do not lead to a reliable diagnosis either – in almost all cases other tests or analyses are needed to confirm the assumed diagnosis.

Proven Telehealth solutions for diagnosis include:

1. Virtual Primary Care Visits

Video-based visits allow rural patients to connect with their primary care provider to evaluate symptoms, review labs, and begin treatment plans. These visits can also serve as entry points for coordinated chronic care management.

Impact: Reduces diagnostic delays, improves continuity of care, and increases engagement with rural patients who may otherwise defer care. For patients with undiagnosed chronic diseases, this can lead to an earlier diagnosis, earlier treatment, and the potential avoidance of developing further health complications.

2. e-Visits for Symptom Review

Structured e-visits (asynchronous questionnaires) enable patients to report chronic symptoms like blood pressure fluctuations or fatigue, which providers can review and triage without scheduling a live visit.

Impact: Offers timely, low-barrier access to care, especially useful for routine symptom check-ins or early signs of disease progression.

Chronic Disease TREATMENT with Telehealth

Once a patient has been diagnosed with one or more chronic conditions, the focus shifts to ongoing management. Chronic care management requires frequent touchpoints — some clinical, some supportive — to keep conditions under control, adjust medications, and reinforce self-management. This is where telehealth integrates most directly with Medicare’s Chronic Care Management (CCM) program, which reimburses practices for structured outreach, medication management, and care plan updates.

Proven telehealth solutions for treatment include:

3. Video Visits with Primary Care Providers

Scheduled telehealth visits allow PCPs to review symptoms, reconcile medications, and update care plans based on recent labs or patient-reported outcomes.

Impact: Supports timely treatment adjustments without requiring travel, sustaining engagement for patients with limited mobility or access.

4. Care Coordinator or Nurse Outreach

Phone or video contacts by non-physician staff — often billed under CCM — support medication adherence, reinforce education, and address patient concerns between visits.

Impact: Strengthens continuity, ensures patients don’t “fall through the cracks,” and allows licensed staff to triage issues before they escalate. Video can also offer a much deeper insight into the patient’s living situation or makes medication reconciliation much easier than describing pills over the phone.

5. Virtual Specialty Care Access

Telehealth extends access to cardiology, pulmonology, endocrinology, and other specialties often missing in rural settings. Routine follow-ups and co-management occur without unnecessary referrals or long travel.

Impact: Brings specialty input into chronic disease management sooner, improves treatment adherence, and builds local provider capacity.

6. E-Consults Between Providers

To enlist the expertise of chronic disease specialists, PCPs can request electronic, asynchronous input from specialists for complex cases, without requiring patients to attend another appointment or even travel to the specialist.

Impact: Accelerates treatment decisions, improves care quality, and reduces patient burden while ensuring timely specialist oversight.

Chronic Disease INTERVENTION with Telehealth

Even the best treatment plans cannot prevent every exacerbation. Chronic care programs must be ready to intervene quickly when patients show signs of deterioration. Telehealth enables a more timely response by extending monitoring into the home and creating pre-determined escalation pathways.

Remote Physiological Monitoring (RPM) data, for example, often provides the first indication of trouble — such as rising blood pressure, fluctuating glucose, or sudden weight gain. When combined with proactive outreach and e-consults, these tools detect the onset of disease early and can prevent hospitalizations and stabilize patients locally.

Proven telehealth solutions for intervention include:

7. Urgent Virtual Primary Care or Specialty Visits

Rapidly scheduled telehealth appointments allow providers to assess symptoms and modify care plans before an ED visit is needed.

Impact: Reduces unnecessary emergency utilization, stabilizes patients at home, and provides peace of mind to families.

8. Urgent Telehealth Escalation Pathways

When RPM data or patient reports flag a potential deterioration, care coordinators initiate secure telehealth outreach — via video, messaging, or rapid scheduling — to escalate the issue to PCPs or specialists.

Impact: Provides a proactive safety net by connecting patients and providers at a distance before conditions worsen into emergencies.

Behavioral Health Care for Chronic Care Management

Chronic physical conditions and behavioral health challenges often go hand in hand. At times it is mental health challenges that manifest as physical diseases. In many cases the burden, especially of multiple chronic diseases, can in turn create depression and other behavioral health disorders.

In general, patients with diabetes, heart failure, COPD, or hypertension are at higher risk of depression and anxiety, which in turn affect their ability to adhere to care plans, take medications consistently, and maintain healthy routines.

For rural patients, behavioral health resources are especially scarce, making telehealth integration a critical enabler. By embedding virtual behavioral health services into chronic care programs, providers can address both the physical and emotional aspects of chronic disease management.

9. Behavioral Health Care for Chronic Care Management

Patients with chronic conditions frequently experience depression, anxiety, or other behavioral health challenges that complicate self-management and adherence. Telehealth-enabled behavioral health services—whether through virtual counseling, integrated screenings, or coordinated follow-up—help address these needs directly within chronic care pathways.

Impact: Improves adherence, enhances patient wellbeing, and strengthens the effectiveness of CCM and remote monitoring.

From Episodic Care to Continuous Care-at-a-Distance

Chronic care management is not a single service but a blend of approaches — video visits, asynchronous check-ins, remote monitoring, specialty consults, and even integrated behavioral health — that together create a more complete and responsive model of care.

Across the nine proven telehealth solutions outlined here, the common thread is their ability to extend the reach of Chronic Care Management (CCM) programs and make care continuous rather than episodic. For rural providers, these tools are already in use today, scalable across different care teams, and adaptable to local infrastructure and patient needs.

Integrating Telehealth-Powered Chronic Care Management into your state’s RHTP application:

As states prepare proposals under the CMS Rural Health Transformation Program, chronic care management represents one of the most strategic opportunities to show impact.

Telehealth-enabled CCM not only improves patient outcomes and quality of life but also reduces avoidable hospitalizations and emergency department use — core measures for sustainability. By incorporating these nine proven solutions, states and rural health systems can demonstrate readiness, cost-effectiveness, and a clear path toward delivering comprehensive, equitable care at a distance.

Do you want to discuss a solid 9-12 month implementation plan to fully integrate many of those telehealth solutions to improve chronic disease management for your clinic? Then reach out to set up a brief Zoom chat.