How Averyn works alongside care management programs
If you (or someone in your family) is enrolled in Chronic Care Management, Remote Patient Monitoring, GUIDE, Principal Illness Navigation, or a similar reimbursed program through your provider — you may be wondering whether you still need a service like Averyn. The honest answer is: it depends on what is happening in your household between the program's calls. This page explains the difference, why both can be needed at the same time, and where Averyn fits.
The reimbursed programs you may already be on
Over the last decade, Medicare and private payers have built out a family of reimbursed care-management programs. They share a structural pattern: a defined patient population, a regular clinical contact cadence, a documentation requirement, and a billing code. They are valuable. They are also bounded.
For patients with multiple chronic conditions. Provider's care team does non-face-to-face coordination, plan-of-care management, and medication review. Documented monthly, billed by time.
Patient uses a connected device (blood pressure cuff, glucose monitor, pulse oximeter) and the care team monitors data, intervenes on alerts, and adjusts the plan. Billed by device days and clinical time.
Similar to CCM but focused on a single high-risk condition that needs ongoing attention. Often used for serious heart failure, COPD, oncology, or other concentrated conditions.
A 30-day post-discharge program that covers an early call, a face-to-face visit, and medication reconciliation. Designed to reduce readmissions in the highest-risk window.
A Medicare model for people living with dementia, providing care navigation, caregiver education and respite, and a care navigator. Eligible practices participate through CMS Innovation Center.
Medicare-reimbursed navigation for people with serious illness expected to last three months or more. Covers assessment, education, and coordination by clinical staff.
Targets social drivers of health — food, transportation, housing, utility access. Care team identifies needs and connects patients to community resources.
A 2025 Medicare bundle covering monthly care-management services across primary care, designed to simplify the patchwork of CCM, PCM, and TCM codes.
Each of these programs is doing valuable clinical work. They identify needs. They review the plan. They coach. They flag escalations. What they do not do, in any of these cases, is run the household execution layer that turns a recommendation into a started service.
The structural gap these programs share
Care-management programs are paid for the clinical work. The execution work — actually calling the vendor, scheduling the intake, chasing the referral, organizing the records across providers, picking up the prescription, arranging transportation, sending the update to siblings — lives outside the reimbursable workflow. The system assumes someone in the household is doing it.
In most households, that someone is one person. Usually an adult child or a spouse. Often working full-time. Sometimes managing care for two parents, or for a spouse who is also enrolled in a care-management program. That person becomes the unpaid project manager for everything between the program's calls.
- Screens for needs and barriers
- Reviews medications and care plan
- Documents care-plan activity
- Recommends resources
- Calls weekly, monthly, or per protocol
- Tracks time and engagement for billing
- Escalates clinical issues
- Calling the resource that was recommended
- Scheduling and rescheduling appointments
- Chasing the referral until it turns into a visit
- Pharmacy, DME, transportation, meals
- Records reconciled across every portal and provider
- Family updates to siblings and in-laws
- The 4–6 hours a week that holds it all together
Where Averyn fits
Averyn is a private-pay, family-directed, explicitly non-clinical service. Each household gets a dedicated Care Continuity Partner (CCP) — a real person with a small caseload — who runs the household execution layer week after week. Records and portals. Scheduling and referral follow-through. Resource activation. Vendors and transportation. Family updates. The Concierge Line for everything that does not have an obvious owner.
Averyn does not replace your care-management program. It does not provide medical advice. It does not handle emergencies. It does not bill Medicare. What it does is close the loop on the recommendations your care-management program is making — so the resource that got mentioned on the call actually starts in the household.
Most care-management programs are very good at the first half — identifying a need, knowing what resource exists, and giving the patient a phone number. The second half is where things stall: the patient has to call, navigate intake, gather paperwork, schedule, coordinate, and follow up. Averyn closes that loop. With family approval, the Care Continuity Partner contacts the resource, completes the intake, schedules the service, coordinates logistics, tracks progress, and reports back. The recommendation in the care plan becomes a started service in the household.
When having both makes sense
A few household patterns where care-management and Averyn complement each other particularly well:
CCM is in place. The recommendations make sense. The daughter coordinating everything between calls works full-time in a different time zone and cannot keep up with the scheduling, vendors, and records. Averyn becomes the local execution layer.
Wife is on RPM for hypertension. Husband has CCM for COPD. The same adult daughter is coordinating appointments, medications, vendors, and family updates for both. Averyn handles the doubled-up execution layer so the two clinical programs can each do their job.
Mom came home last week. CCM and TCM are in place. Home health started. Three specialist follow-ups, a medication change, and scattered records across three systems. Averyn organizes the records, schedules the follow-ups, and aligns the family so the clinical programs can focus on the clinical work.
CHI identified a transportation problem. The care-management team gave the family a list of options. Three weeks later nothing has started because the family never had time to call. Averyn handles intake, scheduling, and tracking so the resource turns into rides.
Multiple specialists, multiple portals, the care-management call, the pharmacy call, the home health call, the patient portal pings. Averyn becomes a single household coordination desk so the family can engage with the program calls that matter without drowning in everything else.
GUIDE provides clinical navigation and caregiver education. The day-to-day execution — pharmacy delivery, transportation, household services, sibling updates, respite coordination — still lands on the caregiver. Averyn handles the execution so the caregiver can use what GUIDE provides.
When Averyn is not what you need
If the recommendations from your CCM, RPM, or GUIDE program are actually getting done in your household — the resources are starting, the appointments are scheduled, the records are organized, the family is aligned — then your program is sufficient. Averyn is for the execution gap. If there is no execution gap, you do not need Averyn.
Averyn does not provide medical advice, triage, urgency determination, diagnosis, treatment, prescription management, or emergency response. If what you need is clinical, talk to your provider, your CCM nurse, or 911 for emergencies. Averyn is the administrative coordination layer, not the clinical one.
Averyn is not home health, not an aide service, and not a caregiver. If your loved one needs help with bathing, dressing, mobility, or other personal care, what you need is home health (if clinically eligible) or private-duty home care. Averyn can help you find and coordinate those services, but it does not provide them directly.
If you need someone to physically come see your loved one, evaluate the home, observe the situation, mediate family conflict, or make professional recommendations about care setting — what you need is a Geriatric Care Manager or Aging Life Care Professional. Averyn works remotely and can help you find a local professional, but it does not replace one.
A 2-minute check on whether you have an execution gap
The Care Coordination Burden Snapshot is a 12-question scored snapshot of the household coordination load. It is the simplest way to see whether Averyn would help in your specific situation — including if you are already enrolled in a care-management program. There are no clinical questions. It takes about three minutes.
Twelve scored questions. Get your burden score (0–24), category breakdown, and tailored next steps. Anonymous to take; the full report is gated behind email.
If you want to talk to your care-management team about Averyn
Most care-management teams are aware of the execution gap and welcome anything that helps the family carry it out. If you want to mention Averyn to your care-management nurse or coordinator, you can keep it simple:
"I'm thinking about using a service called Averyn for the non-clinical coordination at home — records, scheduling, and follow-up on things that get recommended. It's separate from this program and private-pay. Is there anything I should know before I look into it?"
Averyn is independent. Your provider is not endorsing it. You do not need their approval. But it is often useful to mention — especially if your care-management team will eventually be communicating with Averyn (with your authorization) about routine non-urgent coordination.
Start with a short conversation
You don't need everything organized before you reach out. We start by understanding what you're managing and whether Averyn Care is the right fit for your family.
Are you a professional caregiver? See tools and guides for private-duty caregivers