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 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, CCM and PCM across ~30 sites and roughly 100 cardiovascular billing providers.
Two different counts, on purpose. The headline 9,358 is unique patients — enrolled patients, deduplicated because many people carry RPM stacked with CCM or PCM. The 14,520 figure and the enrollment chart below count active program enrollments — enrolled services, one per program per patient. Same population, two lenses. All figures illustrative, modeled — verify against practice data.
Norton Heart & Vascular Institute is the dominant cardiovascular provider in Louisville, and it is not a close contest. 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. It is not a program a practice opts into — 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. This is preliminary — confirm against the final CMS list.
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 — which is a description of what a remote care service line does operationally, 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, CCM 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.
Not a point solution bolted onto one diagnosis — 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 does not put them down: TCM in the transition window, then RPM continuously, with CCM or PCM as the longitudinal 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 unlocks 2–15-day post-episode monitoring windows — 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. |
| Single condition | Principal Care Management | 99426 · 99427 | Heart failure as the principal high-risk condition — the ASM-attributed population, managed as a process. |
| Multi-condition | Chronic Care Management | 99490 · 99439 | The hypertension, CKD and diabetes burden documented beneath the cardiac diagnosis across the Medicare panel. |
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, which is worth confirming in contracting. The modeled figures on this page use locality-resolved CY2026 rates. Illustrative, modeled — verify against the current PFS and the practice's actual localities.
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, trendable, 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.
Claims are generated by the CoachCare billing engine, eliminating 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 CCM and RPM 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, CCM and PCM alike.
RPM device readings, CCM check-ins and PCM condition reviews all 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 not an open-ended check-in — it is a defined sequence, 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 top question a health-system buyer asks about remote care is not the revenue — it is the clinical rigor. 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. 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 | $4,148,709 | $12,838,662 | $16,987,371 |
| Net to practice (after fees) | $1,737,788 | $5,478,157 | $7,215,945 |
| 24-month net reimbursement by program: RPM $7,980,250 · CCM $6,616,457 · PCM $2,390,664 | |||
| Delivered full-service — telephonic enrollment, cellular devices, 24/7 monitoring, documentation and claim generation handled by CoachCare. No new NHVI headcount required to launch. | |||
Figures are illustrative and modeled — verify against practice data. The full model is available as a companion Value Analysis workbook.
Every figure produced here is illustrative and modeled — verify against practice data. Enrollment begins in month 1 in every scenario, ramping to full pathway capacity by month 5.
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.
≈ $8.84M in avoided acute cost at roughly $15K per admission — a system-level benefit, and the same lever ASM measures.
≈ 75.9 FTE-equivalent of monitoring, outreach and documentation performed by CoachCare rather than added to NHVI payroll.
All figures illustrative, modeled — verify against practice data.
CoachCare operates as the service line's engine — enrollment outreach, device logistics, 24/7 monitoring, and billing-ready documentation — while 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. Attribution policy for shared patients (PCM vs. CCM). Protocol sign-off for the heart-failure, CAD and hypertension pathways. 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.
Extend RPM to the CAD and hypertension panels; activate CCM for the multi-condition population; roll to the Southern Indiana sites on the same interface. Monthly scorecard to service-line governance: census, capture rate, revenue per patient-month, decompensation signal.
Formalize the electronic collaborative-care arrangement with the employed primary-care base, harden the titration process, and start Performance Year 1 with an enrolled panel and a documentation trail instead of a project plan. ASM participation is preliminary — confirm against the final CMS list.
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 committed to remote care excellence.
Successful program implementations.
Care plan coding and billing generating over 5 million claims.
Over 100 million vitals recorded and more than 4 million care actions enabled.
Every number on this page traces either to the CoachCare Value Analysis workbook or to cited public data. The key assumptions — including what remains to be confirmed in discovery: