At Coosa Care, we partner with providers and organizations that want to deliver better care without adding more burden to their staff. From independent primary care practices to specialty clinics, rural health centers, ACOs, and hospitals, our care management solutions are designed to adapt to different workflows and patient populations. Whether the goal is closing care gaps, reducing readmissions, improving compliance, or creating new revenue streams, Coosa Care provides the structure, clinical support, and compliance framework to help providers focus on what matters most — caring for patients.
We serve Those who serve.
Primary Care Providers
Primary care providers are at the center of value-based care but often face staff shortages and heavy administrative workloads.
Challenges We Solve:
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Patients miss Annual Wellness Visits due to scheduling and mobility barriers.
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Staff don’t have time to manage monthly CCM and BHI requirements.
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Transitional Care Management follow-ups slip through the cracks.
What Coosa Care Provides:
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In-home and Telehealth AWVs that close gaps and increase compliance.
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End-to-end Chronic Care Management support with monthly patient engagement.
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Behavioral Health Integration monitoring, assessments, and interventions.
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Transitional Care Management to reduce readmissions and support post-discharge patients.
Benefits for Your Practice:
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Generate new recurring revenue streams.
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Improve quality scores and compliance with CMS programs.
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Free your staff to focus on in-office patient care.
How we benefit you
Specialists (Cardiology, Endocrinology, Nephrology, Psychiatry)
Specialty practices treat complex chronic conditions that qualify for CCM and BHI but often lack infrastructure to manage care between visits.
Challenges We Solve:
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Patients struggle with adherence to complex treatment plans.
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Behavioral health comorbidities go unmonitored.
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Care coordination across multiple providers is inconsistent.
What Coosa Care Provides:
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Monthly chronic care engagement to track adherence and escalate issues.
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Behavioral health assessments (PHQ-9, GAD-7) and coaching to support patients holistically.
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Care coordination between specialists, PCPs, and community resources.
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Documentation that ensures CMS compliance and audit readiness.
Benefits for Your Practice:
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Strengthen patient adherence and long-term outcomes.
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Reduce patient no-shows and avoidable hospitalizations.
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Capture additional revenue through CCM and BHI billing.
Rural and community health centers serve large Medicare/Medicaid populations but face staffing shortages and higher chronic disease burdens.
Challenges We Solve:
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Staff stretched too thin to complete AWVs and monthly CCM calls.
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Patients face transportation and social barriers to care.
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Compliance is harder with limited resources.
What Coosa Care Provides:
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Outreach and in-home AWVs to reach patients where they are.
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Chronic care and behavioral health management delivered consistently.
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Coordination with community organizations to address social determinants of health.
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CMS-aligned documentation and reporting.
Benefits for Your Practice:
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Improved access for underserved patients.
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Reliable new revenue streams without adding staff.
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Stronger compliance and quality scores.
Rural Health Clinics (RHCs) & FQHCs
ACOs are rewarded for reducing costs and improving outcomes — and penalized for readmissions and gaps in care.
Challenges We Solve:
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Keeping patients engaged between provider visits.
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Closing care gaps for screenings, chronic management, and behavioral health.
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Meeting CMS quality and compliance benchmarks.
What Coosa Care Provides:
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CCM, BHI, AWV, and TCM programs that align with ACO value-based incentives.
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Patient engagement and monitoring designed to reduce avoidable ER visits.
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Monthly reporting and audit-ready documentation.
Benefits for Your Network:
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Lower total cost of care.
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Stronger compliance with CMS quality programs.
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Increased patient satisfaction and retention.
ACOs & Value-Based Networks
Hospitals & Health Systems
Hospitals face penalties for high readmission rates. Effective Transitional Care Management helps ensure discharged patients receive timely follow-up.
Challenges We Solve:
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Patients fall through the cracks after discharge.
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Follow-up visits within 7–14 days aren’t consistently scheduled.
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Readmissions drive up costs and penalties.
What Coosa Care Provides:
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Post-discharge patient contact within 48 hours.
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Telehealth and in-person follow-ups to meet CMS requirements.
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Medication reconciliation and escalation pathways.
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Care coordination with specialists and PCPs.
Benefits for Your Hospital:
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Reduced readmissions and associated penalties.
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Stronger patient outcomes and continuity of care.
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Better use of clinical staff and resources.