One remote care service line for every Aspirus region, powering heart-failure performance, chronic-disease population health in primary care, and an ambulatory P&L that runs without new hires
Medicare is changing where care happens and how it gets paid. Four shifts are under way at once, and each one lands in the same place: the weeks between a patient’s visits. For a system with 10 Critical Access hospitals across three states, those weeks are spent a long way from the nearest clinic.
Aspirus has spent five years growing into a three-state system: seven northern Wisconsin hospitals in 2021, St. Luke’s and Lake View in 2024, Epic and MyAspirus across all of it by 2025, and a new hospital in Chippewa Falls this fall. The patients it serves are older and rural, and many carry heart failure, hypertension and diabetes at the same time.
Two populations, one program: the heart-failure patients under Aspirus cardiology, and a primary-care Medicare panel where hypertension, diabetes and kidney disease are the norm.
About 5,700 Medicare heart-failure patients sit under Aspirus cardiology. Even at hospitals performing at or better than CMS’s expected readmission rate, about one in five is back within 30 days. Daily weight and blood pressure give days of warning before fluid brings a patient to the emergency department.
Hypertension shows up in about seven in ten Medicare patients in Aspirus primary care and at least three in four in cardiology. Home readings catch what a single office reading misses and let the care team adjust medication month to month instead of visit to visit.
In the primary-care panel, 31% of patients have diabetes, 27% chronic kidney disease and 18% COPD. Most carry two or more chronic conditions, which is exactly the patient chronic care management was written for.
Each step below added hospitals, regions or capability. Click through the years. The next step adds the part none of them covers: what happens after the patient goes home.
Each Aspirus program touches a patient at one moment: a discharge, a clinic visit, a procedure, an afternoon at the Heart Failure Resource Center. A remote care service line connects them, so a patient who leaves one program is still being watched until the next one sees them. Select any program to see what changes.
Aspirus cardiologists and primary-care physicians set the protocols and own every clinical decision. CoachCare staffs and runs the program. Everything runs through the Epic system and MyAspirus portal Aspirus already uses, from the first flag on a patient’s chart to the claim at month end.
The program starts with the panel, not a referral pad. Epic already holds the diagnoses, admissions, vitals and medications. High-risk heart-failure patients in cardiology, and hypertension, diabetes and kidney-disease patients in primary care, are flagged in the chart using criteria Aspirus physicians set, so the right patients surface at discharge, in clinic, or on an outreach list.
Example criteria. Aspirus physicians set and own the flag logic for each condition.
Patients enter at discharge or during an office visit. Either way they land in the same monthly loop: office visits, care management and physiologic monitoring, each one informing the next.
Flagged in Epic before the patient leaves. Devices ordered to the home.
Contact within two business days, medication reconciliation, face-to-face visit in 7–14 days.
TCM 99495 · 99496Readings start right away. The short-month device code covers the first partial month.
99453 · 99445 · 99426Office visits ↻ care management ↻ physiologic monitoring.
BP 162/96 on three agents. The primary-care physician places the remote care order during the visit.
Cellular cuff at home, welcome call, how to take a reading that counts.
99453Home averages drive medication changes month to month; the CCM call covers the other conditions.
99454 · 99457 · 99490Office visits ↻ care management ↻ physiologic monitoring.
The physician orders from the chart, or a CoachCare enrollment specialist working in the clinic enrolls the patient during the visit.
Cellular devices arrive ready to use. No Wi-Fi, no smartphone and no home internet needed, and nothing for the patient to pair.
The patient’s assigned care manager walks through the device, the routine, and who to call.
Readings reviewed, outreach logged, care plan updated, escalations routed. Repeats every month.
From the enrollment flag in Epic to the first billable day of service. Enrollment status is visible in the chart the whole way through, in every region.
Readings that settle are logged in the chart and visible to the physician without paging anyone.
Out-of-range readings get a retake and symptom check first. A confirmed trend goes to the clinician or nurse each region designates, in Epic, with the readings and a recommended next step attached.
A critical value, or chest pain, new shortness of breath or stroke signs on a call: the care team calls 911 with the patient on the line. This cannot be configured away.
At month end, three things come out of the program: clean claims in Epic, an operational report for the service-line owner, and a clinical outcomes report for the physicians.
CoachCare is the only care-management application integrated with Epic that creates claims automatically. No one builds a claim by hand, patient by patient, month by month.
A monthly scorecard for service-line governance. Sample below at the modeled month-12 census.
A 24-month forecast for an Aspirus remote care service line in two arms: heart failure across the cardiology groups, with transitional care at each heart-failure discharge, then chronic-disease care in primary care from month 10. Priced at Wisconsin’s CY2026 Medicare rates, with every patient priced at the Medicare amount, alongside what the program does for patients and for the people who run it.
Four office visits a year leave 361 days with no data. RPM bills only when a patient takes readings on at least 16 days in a month, so an enrolled patient gives the care team at least 192 days of readings a year, wherever they live.
Most heart-failure readmissions start as fluid that builds for days. Daily weight catches it in time for a phone call and a diuretic change, and every heart-failure discharge gets three touches inside two weeks. The program is modeled to avoid about 395 hospitalizations at Aspirus over 24 months.
MercyOne Iowa Heart Center enrolled its 450 most complex heart-failure patients (Stage C–D, NYHA III–IV) in CoachCare RPM with daily weight, BP and heart rate.
St. Luke’s and Lake View’s Enhanced-track ACO is scored on a fixed set of quality measures, and the same measures appear in MIPS reporting across Aspirus. Most of them depend on work this program does every month. Select a measure to see how.
mmHg average drop in Stage 2 hypertension patients across 2,738 patients on CoachCare RPM at Cardiac Solutions, with 94.8% of Stage 2 patients improving and a 6.42 mmHg average drop across the full cohort. Read the case study →
Monitoring thousands of patients turns the panel into a referral pipeline for Aspirus’s specialty programs. Patients surface from their home data, not only when they come in sicker.
Aspirus St. Luke’s is a mandatory TEAM hospital through 2030: coronary bypass, joint replacement, hip fracture, spinal fusion and major bowel surgery are reconciled against 30 days of spending after discharge, about 230 traditional-Medicare episodes a year. Heart failure is not a TEAM episode, and the same post-discharge cadence covers it in every region.
Flagged in Epic for post-discharge monitoring.
Readings start right away. 99445 bills the short first month.
TCM when the patient was discharged from an inpatient stay.
Monthly RPM with PCM or CCM while it adds value.
Every Aspirus hospital, Critical Access included. Daily weight and BP from day two, three touches inside two weeks.
Wausau and Duluth. Watch for heart-failure symptoms, BP and conduction changes in the first weeks.
A TEAM episode at St. Luke’s. Keep BP and heart rate on target while new medications are adjusted.
TEAM episodes at St. Luke’s. Many of these patients also carry hypertension or heart failure into recovery.
Every code the service line bills, at CY2026 Medicare rates for Aspirus’s Wisconsin locality. Build a patient-month to see what one patient is worth.
CY2026 Medicare Physician Fee Schedule, non-facility, Wisconsin locality 00 (NGS, MAC 06302). Minnesota pays a few percent more on the same codes. Only one device code (99454 or 99445), one first-tier management code (99457 or 99470) and one care-management program (PCM or CCM) bill per patient per month. About two-thirds of Medicare patients in Marathon and St. Louis counties are in Medicare Advantage; those plans pay these code families at no less than the Medicare amount, and the forecast prices every patient at the Medicare amount.
Each scenario is a deployment scope. Start with heart failure in cardiology, add hypertension in primary care, or deploy across the full chronic-disease panel. Even the heart-failure-only case is net-positive. Select a scenario to redraw the charts.
| High case: broad deployment | Year 1 | Year 2 | 24 months |
|---|---|---|---|
| Net reimbursement | $1,759,970 | $7,985,510 | $9,745,480 |
| CoachCare cost (fees, implementation, enrollment) | $996,960 | $4,490,641 | $5,487,601 |
| Net to Aspirus after fees | $763,009 | $3,494,870 | $4,257,880 |
| By line: heart failure (RPM + PCM) $4,432,448 · primary care (RPM + CCM) $5,062,549 · transitional care $250,483 in net reimbursement. Margin to Aspirus 43.7%. Net-positive from month 2. Fee-for-service reimbursement only; no episode or shared-savings dollars are in these figures. | |||
Change the assumptions and the 24-month forecast recalculates. Start from a preset or move the sliders yourself. Regional heart-failure counts from Epic are the first thing to plug in.
CoachCare hires, trains and manages the care managers who run the program, at a caseload of 165 patients each. Drag the slider to see the team grow with the census as primary care opens.
The nurses and nurse practitioners in Wausau’s Heart Failure Resource Center, and the cardiology and primary-care teams in every region, keep doing clinical work. The monitoring, outreach and paperwork belong to CoachCare.
Monitoring, outreach and documentation over 24 months on CoachCare’s payroll, plus about 1,159 hours of transitional care.
Hired, trained and managed by CoachCare. Aspirus would otherwise need to recruit and keep them in every region.
An on-site enrollment specialist for each arm, telephonic outreach and device logistics are CoachCare’s expense.
Direct, bi-directional integration with Epic, the system and MyAspirus portal St. Luke’s joined in April 2025. Clinicians never leave the chart. The integration is built once and charged once; the primary-care arm adds patients to it, not a second project.
Epic integration overviewThe same staff, protocols and escalation engine can take on data Aspirus already collects or plans to, so device programs stop needing their own monitoring teams.
Wearable heart-failure sensors that flag fluid and decompensation risk, reviewed alongside daily weight and BP under one care plan.
Ambulatory rhythm and A-Fib burden monitoring, triaged by the same care team and routed to the A-Fib Clinic and Aspirus electrophysiology.
Each new stream is scoped with Aspirus: who reviews, which thresholds, which route. The staffing model and Epic workflow stay the same.
Six reasons this partnership fits Aspirus specifically, not remote care in general.
The program is live in the Aspirus St. Luke’s cardiology clinic. The protocol, the devices, the escalation path and the billing already work in Aspirus’s own workflow, so every other region starts from a running program, not a pilot.
Built once on the Epic system and MyAspirus portal used in all three states, and charged once. Readings, documentation and claims live in Epic, and the primary-care arm adds patients, not a second integration.
CoachCare’s care managers carry the caseload at 165 patients each, about 41 by month 24. Enrollment, devices, 24/7 alert triage and billing preparation are on CoachCare’s payroll, and fees are per active patient per month, with no capital outlay.
Aspirus cardiologists and primary-care physicians set the protocols, sign the care plans and make every clinical decision. Claims go out under Aspirus’s own billing entities and NPIs.
Cellular devices that need no home internet, and a care team that calls. A heart-failure patient discharged from a Critical Access hospital gets the same daily contact as one discharged in Wausau or Duluth.
Zero readmissions in 450 advanced heart-failure patients at Iowa Heart (case study). Half the 30-day readmission rate across 26,689 patients at Cardiac Solutions (case study). A 29.1 mmHg drop in Stage 2 hypertension across 2,738 patients (case study).
The ask: a working session to read the Duluth cohort’s own results, confirm the heart-failure cohort region by region from Epic, scope the Epic build for the other regions, and set the order of the waves, starting with Wausau.
Download the Full Executive Report (PDF)