Norton Heart & Vascular Institute already employs the nurse navigators, the social worker and the dedicated pharmacist who do longitudinal heart-failure work every week. This page is the operating model and the 24-month forecast for turning that existing labor into an Epic-native, net-positive remote care service line: TCM at discharge, then RPM and PCM across ~30 sites and roughly 100 cardiovascular billing providers, phased at a pace a care team can absorb.
Two different counts, on purpose. The headline 6,967 is unique patients, deduplicated because many people carry RPM stacked with PCM. The 8,430 figure and the enrollment chart below count active program enrollments: one per program, per patient. Same population, two lenses.
Norton Heart & Vascular Institute is the largest cardiovascular provider in Louisville by a wide margin. The same public CMS data that documents that volume also documents where the heart-failure outcomes sit relative to the market. Both facts are public. Both point at the same missing layer: what happens to the heart-failure patient between the discharge and the next clinic visit.
52.8% of Louisville's Medicare fee-for-service heart-failure volume — 799 discharges at CCN 180088 plus 106 at Norton Clark. 53.2% of cardiac DRGs. 42.3% of Jefferson County diagnostic catheterizations. No other system in the market is close.
At CCN 180088: 30-day heart-failure mortality 14.3% against a 11.6% national rate — CMS flags it “Worse Than the National Rate.” Excess days in acute care, heart failure: +18.8 per 100 discharges. HRRP heart-failure excess readmission ratio 1.0261. Overall hospital quality star rating: 2.
Baptist Health Louisville, same measures, same period: 12.3% heart-failure mortality, −21.8 excess days per 100, 4 stars. On excess days alone that is a 40.6-day swing per 100 heart-failure discharges between the two campuses.
| CMS Care Compare measure (public data) | Norton Hospitals · CCN 180088 | Baptist Health Louisville | National |
|---|---|---|---|
| 30-day death rate, heart failure (MORT-30-HF) | 14.3% “Worse Than the National Rate” | 12.3% | 11.6% |
| Excess days in acute care per 100 discharges, heart failure (EDAC-30-HF) | +18.8 | −21.8 | 0.0 (reference) |
| HRRP excess readmission ratio, heart failure | 1.0261 | not shown here | 1.0000 (expected) |
| CMS Overall Hospital Quality Star Rating | 2 of 5 | 4 of 5 | — |
Public CMS Provider Data Catalog measures, retrieved July 2026. Presented as published, without adjustment or interpretation beyond CMS's own comparison language. Norton's four adult Louisville hospitals report under a single Medicare CCN (180088), so these measures describe the Louisville adult enterprise as one reporting entity.
CMS's Ambulatory Specialty Model (ASM) is a mandatory, two-sided-risk program that makes individual specialists accountable for the cost and quality of the heart-failure patients attributed to them. Performance Year 1 begins January 1, 2027, carries a Part B payment adjustment of −9% to +9%, and requires an electronic collaborative-care arrangement with primary care. No practice opts in or out. It is a change in how heart failure gets paid.
Four of NHVI's heart-failure cardiologists appear on the CMS CY2027 preliminary ASM participant list, heart-failure cohort — listed under the billing entities Community Medical Associates Inc and Norton Clark Physician Practices LLC.
ASM reconciles attributed heart-failure spend and quality against a benchmark. Year-one adjustments move Part B professional revenue by up to nine points in either direction, escalating through 2031. Downside is not deferred to a later performance year.
ASM requires an electronic collaborative-care arrangement with primary care and structured longitudinal management between visits. That is what a remote care service line does every month, for every enrolled patient.
The sequencing argument is simple: the infrastructure ASM will demand is the infrastructure that pays for itself today. Continuous physiologic monitoring, protocolized titration between visits, and documented care coordination are billable under RPM and PCM right now, under fee-for-service. Build it in 2026 and January 2027 arrives with an enrolled panel and a running workflow instead of a project plan.
A named service line with an owner, a P&L and a scorecard, governed by NHVI cardiologists and running inside Epic. It picks the patient up at discharge and keeps them: TCM in the transition window, then RPM continuously, with PCM as the longitudinal care-management wrapper.
| Stage | Service | CY2026 codes | Cardiovascular use at NHVI |
|---|---|---|---|
| At discharge | Transitional Care Management | 99495 · 99496 | The post-discharge transition window. Billable at discharge and not included in the modeled figures below — upside on top. |
| Enroll & equip | RPM setup & device supply | 99453 · 99454 · 99445 (new for CY2026) | 99445 opens the 2–15-day post-episode monitoring window — built for the patient who just left the hospital. |
| Manage | RPM treatment management | 99457 · 99458 · 99470 (new for CY2026) | Monthly review, guideline-directed medical therapy titration, and escalation on weight and blood-pressure trend. |
| Care management | Principal Care Management | 99426 · 99427 | The single high-risk cardiac condition — or cardiovascular disease as one clinical domain. The ASM-attributed population, managed as a documented monthly process. |
CY2026 Physician Fee Schedule amounts resolve by MAC carrier and locality. Norton's Kentucky sites price to the Kentucky carrier/locality (15102-00); the Southern Indiana sites price to their own Indiana locality — a two-locality service line. The modeled figures on this page use locality-resolved CY2026 rates.
Norton runs a single Epic instance across 100% of its practices and hospitals, with MyNortonChart already in patients' hands and EpicCare Link serving referring providers. That is the cleanest possible integration story: one interface build reaches every NHVI site in Kentucky and Southern Indiana, plus the employed primary-care base that ASM's collaborative-care requirement points at. CoachCare integrates directly and bi-directionally with Epic — the program lives in the chart clinicians already use.
Enrollment flags and trigger ordering sit inside the clinical workflow. The CoachCare team enrolls qualified Medicare patients on NHVI's behalf, health history is exchanged bi-directionally at intake, and enrollment status is visible in Epic in real time.
Device readings land as discrete vitals in the chart, chartable and trendable and usable for titration, not as scanned PDFs. Care summaries and compliance documentation are written back into the record where auditors and quality teams expect to find them.
The CoachCare billing engine generates the claims and removes the manual per-patient, per-month claim step. At a service line enrolling thousands of patients, that is the difference between a program that scales and one that stalls in the business office.
Patients begin receiving RPM and PCM services in fewer than five days from the enrollment flag.
The only care-management application integrated with Epic that provides automated claims creation.
One integration build serves ~30 NHVI sites across Kentucky and Southern Indiana — and the employed primary-care base.
A remote care service line is only as good as what happens the moment a reading looks wrong. This is the governed protocol behind the program — the same discipline that moves 30-day heart-failure mortality and readmission, run as documented decision logic rather than best effort. Norton already employs the nurse navigators, the social worker and the pharmacist who do this work; this is that work operating under a single escalation standard, on RPM and PCM alike.
RPM device readings and PCM condition reviews route through one engine. A critical value escalates on its own, symptoms or not. Anything merely out of range is verified before it ever reaches the practice — so what lands on a clinician's desk is already triaged.
If an active, emergent symptom surfaces during any outreach, the call becomes an emergency call:
The care team calls 911 with the patient still on the line. If the patient refuses, the clinic is looped in; if the clinic can't be reached in the moment, CoachCare activates 911 itself. The patient is never left to make the call alone.
The 72-hour distinction. A change that is recent but not active, reported within the last 72 hours and now resolved, is not treated as an emergency; it routes per the practice's stated preference. The hard pathway is reserved for what is happening right now.
An active emergent symptom or a critical value bypasses everything else and triggers the emergency pathway immediately.
A non-critical finding that still needs clinical attention is routed to a defined member of the practice team — not broadcast, not left in a queue.
A reading that self-resolves or reads stable is documented for the record and surfaced as an FYI — visible, but not an interruption.
Any ER visit or hospitalization in the last 60 days triggers a fixed three-touch cadence over the two weeks where heart-failure readmissions are won or lost. It is a defined sequence rather than an open-ended check-in, and each touch documents and escalates through the same engine.
Identify precipitating factors for the admission · complete medication reconciliation · confirm a PCP or specialist follow-up is booked within 7–14 days · full symptom assessment.
Verify medication adherence · re-evaluate the triggers identified at the first touch · confirm the follow-up appointment actually happened · verify ordered labs were completed.
Medication and risk review · review the outcomes of the completed follow-up visit · symptom re-assessment to confirm the patient is on a stable trajectory out of the high-risk window.
The first question a health-system buyer asks about remote care is about clinical rigor, not revenue. This section is the answer: a single escalation engine, a safety pathway that cannot be overridden, routing that protects physician attention, and a readmission-prevention cadence tied to the exact measures Norton is graded on. The financial model on the next page runs on top of this governance, not instead of it.
A 24-month forecast for the cardiovascular service line, modeled across ~30 NHVI sites and roughly 100 referring cardiovascular providers, against a discovery-stage estimate of the Medicare panel: ~61,400 Medicare patients — roughly 30,000 traditional fee-for-service plus a comparable Medicare Advantage population at Jefferson County's ~51% MA penetration. Two programs: RPM and PCM. Enrollment is governed by a phased rollout cap, not by the size of the panel — the plan below onboards at a pace a care team can absorb. TCM at discharge, ASM performance, and avoided-admission savings are not in these revenue numbers; they are upside on top.
| Line | Year 1 | Year 2 | 24-Month |
|---|---|---|---|
| Total net reimbursement | $1,932,830 | $6,712,738 | $8,645,568 |
| Total CoachCare cost (fees + ancillary) | $1,110,605 | $3,812,477 | $4,923,082 |
| Net to practice (after fees) | $822,225 | $2,900,261 | $3,722,486 |
| 24-month net reimbursement by program: RPM $6,576,194 · PCM $2,069,374 | |||
| Delivered full-service — telephonic enrollment, cellular devices, 24/7 monitoring, documentation and claim generation handled by CoachCare. The on-site enrollment specialist is CoachCare's expense, embedded in the program and never subtracted from practice margin. No new NHVI headcount required to launch. | |||
24-month practice margin: 43.1% of net reimbursement (Year 1 42.5%, Year 2 43.2%).
The full model is available as a companion Value Analysis workbook.
Norton has 100 referring providers. At eight referrals each per month, at an 80% acceptance rate, that is 640 referrals a month of genuine referral supply — more than this or any program can take in. The constraint is not supply. It is that nobody onboards 640 patients a month into a new program, and no care team absorbs it. So the forecast on this page is phased deliberately, and a standing capacity rule caps it at roughly 3,000 unique active patients at month 12 and 7,000 at month 24.
Averaged across year one, rising to about 370 a month once the referral, on-site and telephonic pathways reach their year-one setting.
The second wave activates at month 13. In unique-patient terms that is roughly 247 net-new patients a month in year one and 333 in year two.
At a 165-patient care-manager caseload, 2,969 unique active patients at month 12 needs about eighteen care managers behind them.
6,967 unique active patients at month 24 — a staffing curve the service line can hire against, quarter by quarter.
Enrollment begins in month 1 in every scenario. Acceptance sets the enrollable ceiling for each program; the onboarding pace sets how fast the phased rollout approaches it.
The revenue is one half of the case. The other half is workload: the monitoring, outreach, triage and documentation that a heart-failure program either performs unfunded or does not perform at all. Over 24 months, this is the volume the service line takes on — performed by CoachCare, governed by NHVI.
Recurring, subscription-like professional-fee volume across 24 months — the compounding half of a cardiology P&L.
A continuous clinical picture of the heart-failure, CAD and hypertension panels between visits, landing as discrete vitals in Epic.
≈ $7.27M in avoided acute cost at roughly $15K per admission — a system-level benefit, and the same lever ASM measures.
≈ 37.1 FTE-equivalent of monitoring, outreach and documentation performed by CoachCare rather than added to NHVI payroll.
CoachCare runs the service line's engine: enrollment outreach, device logistics, 24/7 monitoring and billing-ready documentation. NHVI cardiologists govern protocols and own every clinical decision. Full-service delivery means launch requires no new NHVI headcount; the internal staffing model formalizes as census grows.
Named service-line owner, P&L and scorecard. Epic integration scope and billing configuration. Principal-condition attribution policy for PCM. Protocol sign-off for the heart-failure, CAD and hypertension pathways. Agree the site-activation waves and the care-manager hiring curve. Confirm the Kentucky and Indiana locality treatment.
The advanced heart-failure and post-discharge cohorts first — TCM at discharge, RPM continuously, PCM for protocolized titration. Enrollment runs telephonically at CoachCare's expense from the first month, alongside the charter work. Modeled month-3 census: roughly 572 active program enrollments.
Extend RPM and PCM to the CAD and hypertension panels; roll to the next tranche of sites on the same interface. Monthly scorecard to service-line governance: census, capture rate, revenue per patient-month, decompensation signal, and onboarding throughput against the phasing plan.
Formalize the electronic collaborative-care arrangement with the employed primary-care base, harden the titration process, and start Performance Year 1 with roughly 2,969 unique patients enrolled and a documentation trail instead of a project plan. Southern Indiana and the remaining sites open the year-two wave.
The service line described on this page runs on infrastructure already proven at national scale.
Over 400 managed conditions for more than 500,000 patients.
Providers running remote care programs day to day.
Successful program implementations.
Care-plan coding and billing behind more than 5 million claims.
Over 100 million vitals recorded and more than 4 million care actions enabled.
CMS's CY2027 Physician Fee Schedule proposed rule, published July 16, 2026, proposes to reprice remote physiologic monitoring. Here is what it reaches, what it leaves alone, and how the operating model behind this service line absorbs it.
CMS's remote-monitoring proposals sit in one code family: RPM. CCM, PCM, and TCM are not part of them. That distinction lands directly on this forecast — PCM carries $2,069,374 of the modeled $8,645,568 in 24-month net reimbursement, and the TCM touch at discharge is outside the proposal entirely. Neither is in scope.
The delivery model has more than one shape, and CoachCare is preparing each so the service line's economics hold wherever the rule settles. One unbundles the program into its parts — SaaS platform, device logistics, and program enablement — priced as components. Another engages CoachCare to run the staffing itself, an MSO-style arrangement in which the practice owns the clinical program and the billing while CoachCare carries the labor model. Neither requires re-architecting the service line described on this page.
Alongside the fee schedule, CMS's ACCESS Model pays remote care as a risk-based per-member-per-month arrangement rather than per code: recurring per-beneficiary payments, half of each one withheld and reconciled against outcome attainment. Cardiometabolic care is among its four clinical tracks. What earns under that structure — controlled pressures, titrated therapy, decompensations caught early — is what this service line is built to produce.
This forecast repriced code by code at CMS's CY2027 proposed values, at this practice's own MAC locality rather than national averages. Same enrollment, same phasing plan — only the rates move.
Both bars run on the same dollar scale, so the red slice is nearly the same width in each — the same dollars, measured against a larger base. The empty track on the top bar is the care-management revenue RPM alone does not include.
Repriced at this locality's own geographic adjusters. The RPM reductions fall almost entirely on practice expense, so the untouched work component carries more weight in some localities than others; the same repricing at national rates would be −8.8% on RPM. Of the $569,401, RPM accounts for $560,841 and the care-management arm for $8,560.
CY2026 versus CMS's published CY2027 proposed values, shown at national non-facility amounts so they can be read against CMS's own tables. This practice's locality-adjusted amounts differ; the repricing above uses the local figures.
| Code family | What CMS proposed | CY2026 | CY2027 proposed | Change |
|---|---|---|---|---|
| In scope — remote physiologic monitoring | ||||
| 99454 / 99445 · device supply | Practice expense recrosswalked | $52.11 | $41.38 | −21% |
| 99457 · management, first 20 min | Direct practice expense removed | $51.77 | $49.59 | −4% |
| 99458 · management, each addl 20 min | Direct practice expense removed | $41.42 | $40.39 | −2% |
| 99453 · setup and patient education | Crosswalked; one-time per patient | $21.71 | $20.03 | −8% |
| Not in scope — the codes the proposal does not reach | ||||
| 99424–99427 · PCM | No structural change proposed | $67.80 | $67.00 | −1% |
| 99495 / 99496 · TCM | Not addressed by the proposal | Outside the remote-monitoring provisions entirely | ||
National non-facility amounts; CY2027 values are CMS's own published proposals in Addendum B of CMS-1848-P. The care-management rows show the lead code in each family; every code in those families moves within about 4% in either direction, which is ordinary annual movement rather than a repricing. The RPM reductions are also phased — section 1848(c)(7) of the Act caps any one code's total-RVU reduction at 19% in a single year, and CMS publishes the affected codes, so CY2027 is a single-digit year for a typical program and the remainder arrives no earlier than CY2028.