For years, healthcare has talked about “care coordination.” Under the new CMS Ambulatory Specialty Model (ASM), it becomes much more than a best practice — it becomes an expectation.
Beginning January 1, 2027, eligible cardiologists participating in ASM will be evaluated not only on the quality and cost of the care they provide, but also on how effectively they coordinate care with primary care physicians. CMS believes stronger collaboration between specialists and primary care providers can help improve outcomes for patients with chronic heart failure while reducing avoidable hospitalizations and unnecessary healthcare spending.
In other words, no one provider is expected to manage these complex patients alone.
But successful coordination doesn’t happen simply because providers agree it is important. It requires the right people, processes, technology, patient engagement and communication workflows. That is where Cardiac RMS can play an important role — helping cardiology practices build the remote monitoring and patient engagement infrastructure needed to support more proactive, connected care.
Heart failure patients often have multiple chronic conditions, including hypertension, diabetes, kidney disease, obesity or COPD. While the cardiologist focuses on managing heart failure, the primary care physician may oversee many of these additional health concerns.
Without regular communication between providers, important pieces of a patient’s care can fall through the cracks. Medication changes may not be shared. Symptoms may go unreported. Follow-up appointments can be missed. Small changes in a patient’s condition may go unnoticed until they become serious enough to require an emergency room visit or hospitalization.
CMS wants to change that.
ASM encourages participating specialists to work proactively with primary care — sharing information, coordinating treatment plans and identifying problems before they become medical emergencies. CMS specifically requires participating specialists to complete improvement activities focused on connecting with primary care and establishing collaborative care arrangements that define communication and care coordination expectations.
Cardiac RMS can help support that connection between visits. Through remote monitoring, patient engagement and clinical workflow support, Cardiac RMS helps cardiology practices stay closer to their patients and identify information that may require attention, intervention, or communication with other members of the care team.
When providers share information consistently, patients benefit. A collaborative approach can help practices:
These are exactly the types of outcomes CMS is seeking to encourage under ASM.
But achieving them requires more than good intentions. Practices need consistent monitoring, patient follow-up, documentation and defined clinical workflows so important information is identified and acted upon appropriately.
Cardiac RMS works as an extension of the cardiology practice, helping support many of these day-to-day processes. That becomes increasingly important as success in heart failure care is measured not simply by what happens during an office visit, but by what happens to the patient in the weeks and months between visits.
Effective collaboration doesn’t have to mean more meetings or endless phone calls. What practices need is timely, actionable information.
Remote patient monitoring and structured patient engagement programs can help cardiology practices monitor patients between office visits, identify concerning trends earlier and document interventions before conditions worsen. When appropriate, relevant information can also be communicated to the patient’s primary care physician, helping everyone involved make more informed clinical decisions.
Someone still needs to monitor the data, recognize meaningful changes, engage the patients, support follow-up and help ensure actionable information reaches the appropriate clinical team.
That is area where Cardiac RMS brings together technology, clinical expertise, patient engagement and workflow support.
Rather than adding another task to an already busy practice, Cardiac RMS can help provide the infrastructure behind remote care so cardiologists and their teams can focus on clinical decision-making and their patients.
ASM signals a broader shift in healthcare. Success will increasingly depend on prevention, early intervention, patient engagement and coordinated care rather than simply treating illness after it occurs.
Practices that develop these capabilities and communication processes now will be better positioned when ASM begins in January 2027 and for the next five years. Those that wait may find themselves trying to create new workflows while already being measured against new performance standards.
That asks the question for cardiology practices bigger than: “Do we understand ASM?”
The more important questions may be:
For more than a decade, Cardiac RMS has worked alongside cardiology practices to help address these very challenges through remote monitoring, heart failure care, patient engagement and clinical workflow support.
ASM may be new, but many of the capabilities it emphasizes are not.
January 2027 is approaching. Now is the time to determine where your practice is prepared and where there may still be gaps.
Talk with Cardiac RMS now about your current remote monitoring, patient engagement, and care coordination workflows and how they may need to evolve for ASM.
Call 844-GET-CRMS or email michael.mantzouris@docgo.com to schedule a no-obligation appointment.
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