RPM for Home Health
Remote Patient Monitoring for Home Health — Powered by MatrixCare + CCN Health
Purpose-built RPM for Home Health communities. CCN Health integrates directly with MatrixCare to automate clinical workflows and capture every eligible reimbursement.
CCN Health provides a certified Remote Patient Monitoring (RPM) integration with MatrixCare designed specifically for home health agencies. The platform automates clinical documentation, enables real-time monitoring, and generates Medicare billing records for compliant reimbursement.
Remote Patient Monitoring for Home Health with MatrixCare
Home Health agencies face unique challenges managing patient health: monitoring patients between home visits when clinicians are not present and detecting health deterioration early enough to prevent hospitalization. CCN Health's RPM integration with MatrixCare addresses these challenges with automated monitoring, documentation, and billing.
Home Health Challenges That RPM Addresses
- Monitoring patients between home visits when clinicians are not present
- Detecting health deterioration early enough to prevent hospitalization
- Coordinating care across multiple home health team members
- Ensuring device compliance when staff cannot supervise daily use
How It Works in Home Health
- Device Assignment — FDA-cleared devices (blood pressure cuffs, scales, pulse oximeters, or sensorless monitors) are assigned to the patient
- Automatic Data Capture — Vitals transmit via cellular gateway to the CCN Health platform without manual entry
- MatrixCare Integration — Data flows directly into MatrixCare patient records via api integration
- Clinical Alerts — Abnormal readings trigger real-time notifications to care staff within 2 minutes
- Billing Automation — CPT codes 99453, 99454, 99457, 99458 documented automatically for compliant billing
Why Home Health Agencies Choose CCN Health
Between-Visit Monitoring
Continuous data capture fills the gaps between scheduled home visits with objective vital sign data.
Reduced Hospitalizations
Early alerts enable clinical response before conditions require emergency department visits.
Clinician Efficiency
Automated charting reduces documentation burden, allowing clinicians to focus on direct patient care.
Care Coordination
All team members see the same data, improving handoff quality and continuity.
Devices for Home Health RPM
| Device | Use Case | Patient Experience |
|---|---|---|
| Blood Pressure Monitor | Hypertension, heart disease | Automated cuff — press one button, reading transmits automatically |
| Weight Scale | Heart failure, nutrition monitoring | Step on scale daily, no buttons required |
| Pulse Oximeter | COPD, respiratory conditions | Finger clip for 30 seconds, automatic transmission |
| Dexcom G7 CGM | Diabetes management | Small sensor on arm, continuous readings without fingersticks |
| Xandar Kardian Sensor | General wellness, fall risk, sleep | Wall-mounted radar — completely contactless |
Clinical Benefits for Home Health
Chronic Disease Management
Monitor patients with conditions like heart failure, COPD, diabetes, post-surgical. Trending data helps care teams adjust care plans before conditions deteriorate.
Transition of Care Support
When patients return from hospital stays, RPM enables closer monitoring during the critical post-discharge period.
Billing & Reimbursement in Home Health
CCN Health automates Medicare RPM billing documentation for qualified patients:
| CPT Code | Reimbursement | Requirements |
|---|---|---|
| 99453 | ~$19 | One-time device setup and patient education |
| 99454 | ~$50/mo | 16+ days of readings per 30-day period |
| 99457 | ~$48/mo | First 20 minutes of clinical monitoring time |
| 99458 | ~$38/mo | Each additional 20 minutes of clinical time |
Monthly potential per patient: $120+
Frequently Asked Questions
Does CCN Health integrate with MatrixCare for home health RPM?
Yes. CCN Health's certified MatrixCare integration enables bi-directional data flow specifically designed for home health workflows.
What is the implementation timeline for home health?
Most home health agencies are fully operational within 4 weeks, including integration setup, clinical team training, and device deployment.
How does RPM billing work in home health?
CCN Health automatically documents the required data for 99453, 99454, 99457, 99458. Time tracking and transmission records are captured for audit-ready Medicare billing.
Implementation for Home Health
| Week | Activity |
|---|---|
| 1 | Discovery call and MatrixCare configuration review |
| 2 | Technical integration setup and testing |
| 3 | Clinical team training and device deployment |
| 4 | Pilot launch with select patients |
| 5+ | Full agency rollout and optimization |
Discovery call — we learn your workflows, EHR setup, and resident population.
CCN's AI engine configures optimal alert thresholds and EHR data mapping around your facility's patterns.
Go live with AI-powered monitoring, automated documentation, and billing — your team stays focused on care.
No one-size-fits-all templates. Every integration is configured for how your Home Health actually operates.
Book a Discovery CallAI-Powered Alerts
Pattern recognition catches changes early
Smart Workflows
Automated routing and documentation
Automated Compliance
Real-time audit trail and billing validation
Advanced intelligence working behind the scenes — faster processing, smarter alerts, effortless documentation.
Technology that stays in the background — so care stays in the foreground.
Why CCN Health
Why Home Health Facilities Choose CCN Health
Purpose-built technology that fits your clinical workflows and drives measurable outcomes.
Seamless EHR Integration
How CCN Health Works Inside MatrixCare
Your monitoring data flows directly into MatrixCare — no exports, no manual entry, no disruption to your clinical workflow.
RPM Devices
CGM, Scales, BP, SpO2
AI-Powered Platform
Intelligent data routing, anomaly detection, and automated documentation — working behind the scenes.
MatrixCare
Charts & Care Plans
What Flows Between Systems
Patient Demographics
Conditions, medications, and census sync from your EHR
Vital Observations
Device readings flow automatically into patient charts
Discharge & ADT Events
Admission and discharge events trigger protocol changes
Care Plans
Treatment plans inform monitoring thresholds and alerts
Billing Documentation
CPT-ready records generated for claims submission
Cross-Program Data
RPM data available for CCM, PCM, BHI — no re-entry
“Every reading, every alert, every care plan update — available across all your programs. One integration, unlimited use cases.”
Infrastructure
Devices & Billing
FDA-cleared devices and automated Medicare billing — configured per resident, synced with the EHR.
Supported Devices
The Xandar Kardian sensor captures heart rate, respiratory rate, and room presence using radar technology — residents don't wear, charge, or interact with anything.
Medicare Billing
Remote Patient Monitoring (RPM)
4 billing codes
Initial setup and patient education on monitoring equipment
~$19
One-time
Device supply with daily recording or programmed alert transmission
~$50
Monthly
First 20 minutes of clinical staff time for RPM treatment management
~$50
Monthly
Each additional 20 minutes of RPM treatment management
~$40
Monthly (additional)
Common Questions
Frequently Asked Questions
Everything you need to know about implementation, billing, and clinical workflows.
Yes. CCN Health integrates with MatrixCare to deliver monitoring data into post-acute care workflows, supporting RPM and CCM programs across skilled nursing and senior living.
RPM uses FDA-cleared connected devices to collect patient vitals—such as blood pressure, weight, and glucose—outside of traditional clinical settings, enabling proactive care and early intervention.
The primary RPM CPT codes are 99453 (device setup), 99454 (monthly device supply/data transmission), 99457 (first 20 min clinical review), and 99458 (each additional 20 min).
Home health agencies use RPM to monitor patients between visits, receive real-time alerts for concerning readings, and document care coordination to support billing and compliance.
Most facilities are fully operational within 2–4 weeks. CCN Health handles device provisioning, EHR integration setup, staff training, and ongoing clinical support.
Still have questions? We're happy to walk you through anything.
Talk to Our TeamGet Started
Ready to bring Remote Patient Monitoring to your Home Health?
See how CCN Health can improve resident outcomes, preserve independence, support family engagement, and generate new Medicare revenue — all within the EHR your staff already uses.