Care Models & Pathways

One Infrastructure. Multiple Ways to Deliver Continuous Care.

Two clinicians walking through a hospital hallway

One Connected Operating System Across Care Models & Pathways

Healthcare is moving beyond episodic visits toward care that is continuous, coordinated, and increasingly delivered between traditional encounters. Brook provides one connected infrastructure to deliver and scale care across advanced primary care, remote monitoring, chronic care management, specialty pathways, and value-based care—extending the same patient relationship as needs evolve.

APCM

Advanced Primary Care Management

Comprehensive, longitudinal care management that connects care planning, engagement, medication support, coordination, and population health.

RPM

Remote Patient Monitoring

Connected physiologic monitoring combined with ongoing engagement and clinical support to identify changes and support timely intervention.

CCM

Chronic Care Management

Ongoing care planning, engagement, medication support, and coordination for patients managing multiple chronic conditions.

Specialty Care Pathways

Medication Management, Brain Health & More

Specialized pathways that extend continuous support to medication management, brain health, and other evolving clinical needs.

VBC

Value-Based Care

Continuous population support designed to improve outcomes and quality performance while reducing avoidable utilization.

Advanced Primary Care Management (APCM)

Infrastructure for the Next Generation of Primary Care

Advanced Primary Care Management (APCM) is a Medicare service designed to support comprehensive, longitudinal primary care. Unlike traditional time-based care management services, APCM uses a monthly bundled payment model based on patient complexity.

APCM brings together many of the capabilities required for advanced primary care—including comprehensive care management, patient-centered care planning, medication management, care transitions, enhanced communication, population-level management, and performance measurement. CMS introduced APCM beginning in 2025 and uses three HCPCS codes reflecting patient complexity.

How Brook Enables APCM

Brook helps primary care organizations operationalize comprehensive, longitudinal care across their patient population—connecting care planning, ongoing patient access, coordination, and population management within one model.

Comprehensive Care Planning

Maintain a personalized, longitudinal care plan that evolves with the patient’s conditions, goals, treatment, and needs.

Comprehensive Care Planning

Maintain a personalized, longitudinal care plan that evolves with the patient’s conditions, goals, treatment, and needs.

Population Management

Identify and engage eligible populations, understand changing needs, and help care teams prioritize patients requiring additional attention.

Population Management

Identify and engage eligible populations, understand changing needs, and help care teams prioritize patients requiring additional attention.

Access & Ongoing Communication

Extend the primary care relationship beyond scheduled appointments through ongoing patient communication and care-team support.

Access & Ongoing Communication

Extend the primary care relationship beyond scheduled appointments through ongoing patient communication and care-team support.

Care Coordination & Transitions

Coordinate across specialists, referrals, settings, and transitions to maintain continuity of care.

Care Coordination & Transitions

Coordinate across specialists, referrals, settings, and transitions to maintain continuity of care.

Whole-Patient Management

Connect chronic conditions, medications, preventive needs, and other aspects of the patient’s care rather than managing each in isolation.

Whole-Patient Management

Connect chronic conditions, medications, preventive needs, and other aspects of the patient’s care rather than managing each in isolation.

APCM Operations & Performance

Support the workflows, documentation, reporting, and performance requirements needed to operate APCM at scale.

APCM Operations & Performance

Support the workflows, documentation, reporting, and performance requirements needed to operate APCM at scale.

What Patients Experience

Patients receive more consistent support beyond scheduled appointments, including access to a care team, help understanding and following their care plan, medication support, health education, care coordination, and help navigating next steps.

Primary care that stays connected to the patient; not just the appointment.

Remote Patient Monitoring (RPM)

Turn Remote Monitoring Into Continuous Care

Remote Patient Monitoring (RPM) enables patients to collect physiologic health information, such as blood pressure, weight, or glucose, using connected medical devices that transmit information for use in managing their condition.

RPM gives care teams greater visibility into what’s happening between visits. But data alone isn’t care. The opportunity is turning that information into meaningful engagement, timely support, and appropriate clinical intervention.

How Brook Enables RPM

Brook turns remotely collected physiologic data into an ongoing care experience—connecting monitoring with patient engagement, clinical review, and appropriate intervention.

Connected Device Enablement

Support device deployment, onboarding, connectivity, and collection of relevant physiologic data from home.

Connected Device Enablement

Support device deployment, onboarding, connectivity, and collection of relevant physiologic data from home.

Continuous Monitoring & Trend Detection

Track readings longitudinally to identify meaningful trends, changes, and gaps in monitoring.

Continuous Monitoring & Trend Detection

Track readings longitudinally to identify meaningful trends, changes, and gaps in monitoring.

Clinical Review & Prioritization

Help care teams focus attention on patients and readings that warrant review rather than simply generating more data.

Clinical Review & Prioritization

Help care teams focus attention on patients and readings that warrant review rather than simply generating more data.

Interactive Patient Management

Engage patients around their readings, symptoms, treatment, medications, and health goals.

Interactive Patient Management

Engage patients around their readings, symptoms, treatment, medications, and health goals.

Clinical Escalation

Surface concerning changes through established provider workflows to support timely clinical intervention.

Clinical Escalation

Surface concerning changes through established provider workflows to support timely clinical intervention.

RPM Operations

Support device logistics, monitoring workflows, documentation, and reimbursement operations.

RPM Operations

Support device logistics, monitoring workflows, documentation, and reimbursement operations.

What Patients Experience

Depending on their care plan, patients may receive connected health devices, help getting started, ongoing monitoring, access to a Brook care team, personalized education and coaching, medication and treatment support, and outreach when their health information indicates they may need additional attention.

Monitoring becomes an ongoing connection between the patient and their care team.

Chronic Care Management (CCM)

Ongoing Support for People Managing Multiple Chronic Conditions

Chronic Care Management (CCM) provides ongoing care management and coordination for eligible Medicare patients living with two or more chronic conditions expected to last at least 12 months or until death and that place the patient at significant risk.

For patients whose health needs extend well beyond periodic office visits, CCM creates a structured model for providing ongoing support throughout the month.

How Brook Enables CCM

Brook extends chronic disease management beyond periodic visits, giving patients with multiple chronic conditions consistent support throughout the month.

Longitudinal Chronic Care Plan

Maintain a comprehensive care plan spanning the patient’s multiple chronic conditions and treatment goals.

Longitudinal Chronic Care Plan

Maintain a comprehensive care plan spanning the patient’s multiple chronic conditions and treatment goals.

Ongoing Care Management

Provide structured, recurring support throughout the month rather than relying on episodic encounters.

Ongoing Care Management

Provide structured, recurring support throughout the month rather than relying on episodic encounters.

Medication & Treatment Adherence

Help patients understand and follow medications and treatment recommendations across multiple conditions.

Medication & Treatment Adherence

Help patients understand and follow medications and treatment recommendations across multiple conditions.

Condition Education & Self-Management

Help patients understand their conditions, recognize relevant changes, and build the skills and behaviors needed to manage their health.

Condition Education & Self-Management

Help patients understand their conditions, recognize relevant changes, and build the skills and behaviors needed to manage their health.

Care Coordination & Navigation

Coordinate across providers, specialists, services, and follow-up needs that become more complex for multi-condition patients.

Care Coordination & Navigation

Coordinate across providers, specialists, services, and follow-up needs that become more complex for multi-condition patients.

CCM Operations & Documentation

Support the time-based workflows, documentation, care-plan requirements, and reimbursement processes associated with CCM.

CCM Operations & Documentation

Support the time-based workflows, documentation, care-plan requirements, and reimbursement processes associated with CCM.

What Patients Experience

Patients receive an additional layer of support between visits; a care team that can help them understand their health and care plan, stay on track with medications and treatment, build healthier habits, coordinate care, and navigate questions or changes in their health.

Continuous support for patients managing multiple chronic conditions.

Use Cases

See how APCM RPM, and CCM and other continuous care pathways come together in real patient journeys, connecting monitoring, engagement, medication support, and clinical coordination around each patient’s needs.

Use case 1

53-year-old man

CONDITIONS

Heart failure · Hypertension

CARE PROGRAM

RPM + CCM

Overview

Prior to enrollment, the patient had 6 hospital admissions in 12 months while managing CHF and hypertension, with education gaps around disease management, medications, and the importance of consistent follow-up.

Clinical event

The Brook care team identified an uptrend in weight indicative of an early-stage heart failure exacerbation. The nurse also identified a missed follow-up appointment.

Interventions

Brook nurse reviewed clinical status and weight trend for signs of worsening CHF.

Provided disease-state and medication education, reinforcing the importance of consistent follow-up.

Coordinated with the clinic to address the missed appointment and support timely follow-up.

Continued comprehensive monitoring and care coordination across the patient’s CHF and hypertension.

Engagement & adherence

Brook provides ongoing monitoring, education, and care coordination to help the patient better understand and manage CHF and hypertension between visits.

Outcome & follow-up

The patient has had zero hospital admissions in the 6 months since enrollment. The patient now has consistent follow-up, ongoing education, and comprehensive, coordinated support to better manage his health.

This case demonstrates how whole-person RPM + CCM can combine early clinical detection, education, and care coordination to help a high-risk patient gain control of chronic conditions and reduce acute-care utilization.

74-year-old man

CONDITIONS

Heart failure · Hypertension · Type 2 diabetes

CARE PROGRAM

CCM + RPM

Overview

The patient is managing CHF, hypertension, and type 2 diabetes, with multiple medications and overlapping clinical risks requiring ongoing chronic care support.

Clinical event

Over several days, Brook identified increasing weight and blood pressure trends. During outreach, the patient also reported new lower-extremity swelling and mild shortness of breath.

Interventions

Brook nurse reviewed weight and trends, symptoms, medications, and recent adherence.

Escalated findings to the provider because of concern for early fluid overload / CHF exacerbation.

Reinforced provider-directed treatment changes with the patient.

Increased follow-up while continuing to monitor weight, BP, symptoms, and overall chronic-care needs.

Engagement & adherence

The patient is consistently engaged with connected monitoring and regular Brook care-team support for symptoms, medications, education, and chronic-condition management.

Outcome & follow-up

Subsequent monitoring showed weight and blood pressure trending toward the patient’s baseline, with improvement in reported symptoms. Brook continued CCM support across the patient’s conditions and medications.

This case shows how CCM + RPM creates one continuous view of a complex patient—connecting physiologic trends, symptoms, medications, and multiple chronic conditions before deterioration becomes acute.

78-year-old woman

CONDITIONS

Type 2 diabetes · Hypertension

CARE PROGRAM

APCM

Overview

Referred to Brook for longitudinal management of type 2 diabetes and hypertension, with multiple medications and ongoing care needs between primary care visits.

Clinical event

During routine outreach, the patient reported increasing dizziness following a recent medication change and uncertainty about which blood pressure medications she should be taking.

Interventions

Brook nurse completed a medication reconciliation and identified a discrepancy between the patient’s current regimen and recent instructions.

Reviewed symptoms and available blood pressure and glucose information for additional clinical context.

Coordinated with the primary care provider to clarify the treatment plan.

Reinforced updated instructions and coordinated appropriate follow-up.

Engagement & adherence

Through APCM, the patient maintains an ongoing relationship with the Brook care team for care-plan support, medication questions, follow-up, and emerging health needs.

Outcome & follow-up

The medication discrepancy was resolved without waiting for the next office visit. At follow-up, the patient reported improved understanding of her medications and resolution of the dizziness, with Brook continuing longitudinal support.

This case shows how APCM extends primary care between visits—coordinating medications, chronic conditions, follow-up, and emerging needs through one continuous care relationship.

72-year-old woman

CONDITIONS

Type 2 diabetes

CARE PROGRAM

RPM + CCM

Overview

Referred to Brook for management of poorly controlled type 2 diabetes, with glucose levels remaining above goal despite an established medication regimen.

Clinical event

Brook identified a persistent pattern of elevated glucose readings, including repeated fasting values above the patient’s target range.

Interventions

Brook nurse reviewed glucose trends, medication use, diet, and adherence with the patient.

Shared longitudinal glucose data and findings with the provider to support treatment adjustment.

Reinforced medication adherence, nutrition, and glucose-management education.

Continued RPM monitoring to assess response between visits.

Engagement & adherence

The patient is consistently engaged with connected glucose monitoring and the Brook care team for education, medication support, and lifestyle coaching.

Outcome & follow-up

Following intervention, the patient demonstrated improved glucose trends and greater consistency with monitoring and medication adherence. Brook continues to monitor progress and coordinate with the provider as needed.

This case shows how RPM + CCM connects daily glucose data with coaching, medication support, and provider action to improve diabetes management.

Care & Reimbursement Scenarios

Multiple Ways to Deliver and Sustain Continuous Care

Different patients require different levels and types of support. Depending on patient needs, eligibility, and applicable requirements, continuous care may be delivered through individual or complementary care models.

Brook provides one infrastructure to support these models, helping organizations connect care delivery with the operational workflows and reimbursement needed to scale.

Example patient reimbursement scenarios

What potential reimbursement scenarios could look like with the interplay of RPM, CCM and APCM.

Scenario 1: HTN patient with intermittent data (RPM & APCM)

99445

10 days of BP readings

$44-$50

99470

15 min of clinical management

$22-$28

G0556

One chronic condition

$15-$21

Total monthly reimbursement (RPM & APCM):

~$81-$99

Scenario 2: CHF patient w. consistent monitoring (RPM & APCM)

99454

>16 days device data

$44-$50

99457

20 min management

$48-$52

G0557

2+ chronic conditions

$48-$55

Total monthly reimbursement (RPM & APCM):

~$140-$157

Scenario 3: Diabetic patient needing non-complex support (RPM & CCM)

99454

>16 days device data

$44-$50

99490

Non-complex CCM (≥20 min time/month)

$60-$66

Total monthly reimbursement (RPM & CCM)

~$104-$116

Scenario 4: Complex patient w consistent monitoring (RPM & CCM)

99454

>16 days device data

$44-$50

99487

Complex CCM ≥60 minutes/month

$132-$140

Total monthly reimbursement (RPM & CCM):

~$176-$190

View full CPT reimbursement by code

Specialty Care Pathways

Extend Continuous Care Around Specific Clinical Needs

Not every patient need fits neatly within a single reimbursement model.

Brook’s infrastructure can support specialized pathways built around specific conditions, treatments, and populations; bringing together clinical protocols, personalized care plans, ongoing engagement, medication support, and care coordination.

Medication Management

Extend medication support beyond the prescription.

Support medication reconciliation, patient education, adherence, treatment-plan reinforcement, ongoing follow-up, and provider-directed medication management.

For patients: Personalized support understanding medications, staying on track with treatment, addressing adherence barriers, and communicating medication-related questions or concerns to their care team.

Brain Health

Continuous support for cognitive and brain health.

Extend provider-directed brain health pathways with ongoing patient engagement, education, assessment, coaching, and care coordination.

For patients: Personalized guidance, education, engagement, and ongoing support based on individual needs and care plans.

Cardiometabolic Care

Connected support across interconnected conditions.

Support patients managing hypertension, diabetes, obesity, and related cardiometabolic conditions through monitoring, personalized care plans, medication support, coaching, and ongoing engagement.

For patients: Help understanding their condition, tracking relevant health information, following medications and treatment plans, and making sustainable lifestyle changes.

Cardiovascular Care

Stay connected to patients between visits.

Extend care for hypertension, heart failure, and other cardiovascular conditions through monitoring, medication support, education, ongoing engagement, and clinical care coordination.

For patients: Depending on their care plan, connected monitoring, regular care-team outreach, medication and treatment support, personalized education, coaching, and follow-up when health information changes.

Additional specialty pathways can be configured as clinical and organizational needs evolve.

Value-Based Care

Continuous Care Built Around Outcomes

Value-based care shifts the focus from individual services and encounters toward quality, outcomes, patient experience, and total cost of care.

Success requires healthcare organizations to understand and influence what happens beyond individual visits, where much of chronic disease management takes place.

Brook provides the continuous care infrastructure to help organizations stay connected to attributed populations, identify changing needs, manage chronic disease, close care gaps, and engage patients over time.

How Brook Supports Value-Based Care

Population Identification & Prioritization

Identify patients who may benefit from additional support and prioritize care based on needs and risk.

Population Identification & Prioritization

Identify patients who may benefit from additional support and prioritize care based on needs and risk.

Continuous Patient Engagement

Maintain relationships with patients beyond individual encounters.

Continuous Patient Engagement

Maintain relationships with patients beyond individual encounters.

Chronic Disease Management

Support patients managing hypertension, diabetes, heart failure, and other chronic conditions.

Chronic Disease Management

Support patients managing hypertension, diabetes, heart failure, and other chronic conditions.

Medication & Treatment Support

Help patients understand and follow medications, treatment plans, and recommended care.

Medication & Treatment Support

Help patients understand and follow medications, treatment plans, and recommended care.

Care Gap Support

Engage patients around preventive care, recommended follow-up, and other identified needs.

Care Gap Support

Engage patients around preventive care, recommended follow-up, and other identified needs.

Care Coordination

Connect patients, providers, specialists, services, and next steps across the care continuum.

Care Coordination

Connect patients, providers, specialists, services, and next steps across the care continuum.

Earlier Identification & Intervention

Use longitudinal information and ongoing engagement to identify meaningful changes that may warrant attention.

Earlier Identification & Intervention

Use longitudinal information and ongoing engagement to identify meaningful changes that may warrant attention.

Outcomes & Performance

Provide visibility into clinical, engagement, and operational performance across populations.

Outcomes & Performance

Provide visibility into clinical, engagement, and operational performance across populations.

What Patients Experience

More consistent support between healthcare encounters—including personalized guidance, health education, medication and treatment support, coaching, care coordination, and help staying connected to recommended care.

Move from managing individual encounters to supporting the health of populations over time.

Care That Adapts as Patient Needs Change

One Continuous Relationship. Multiple Paths to Care.

Patients don’t remain static; and their care shouldn’t either.

A patient may initially need monitoring, later require additional medication or chronic care support, or benefit from a broader longitudinal primary care model. Brook allows organizations to evolve care around changing patient needs while maintaining a consistent patient experience.

Identify

Patients enter Brook through provider referral, population identification, discharge workflows, or other eligible pathways.

Identify

Patients enter Brook through provider referral, population identification, discharge workflows, or other eligible pathways.

Adapt

New data, patient interactions, and changing clinical needs inform how support evolves over time.

Adapt

New data, patient interactions, and changing clinical needs inform how support evolves over time.

Personalize

Brook’s care team establishes an individualized care plan aligned to provider direction, clinical needs, and patient goals.

Personalize

Brook’s care team establishes an individualized care plan aligned to provider direction, clinical needs, and patient goals.

Coordinate & Escalate

When additional attention is needed, Brook coordinates with the provider and supports the appropriate next step.

Coordinate & Escalate

When additional attention is needed, Brook coordinates with the provider and supports the appropriate next step.

Engage

Patients receive the appropriate combination of monitoring, education, coaching, medication support, and care coordination.

Engage

Patients receive the appropriate combination of monitoring, education, coaching, medication support, and care coordination.

Same patient relationship. The right support as needs evolve.

Built for Today’s Care Models – and What’s Next

Care delivery and reimbursement will continue to evolve.

Brook provides a common infrastructure healthcare organizations can use across APCM, RPM, CCM, specialty pathways, and value-based care—without rebuilding the technology, clinical, engagement, and operational model for every new service.

One infrastructure. One continuous patient relationship. Multiple paths to better care.

Build the Right Continuous Care Model for Your Organization

Whether you’re implementing APCM, scaling remote monitoring, strengthening chronic care management, developing specialty pathways, or expanding value-based care, Brook provides the infrastructure to make continuous care operational.