The Whole-Person Connected Care Platform
One Platform for Whole-Person, Remote Connected Care
Care is episodic. Your patients’ lives aren’t. TraceWell Health keeps clinical, behavioral, and nutrition care connected between visits — and measures what happens next.
The Gap Between Visits Is Where Care Breaks Down
- Readmissions tied to changes that were visible in the data but caught too late
- Clinical staff drowning in alerts that don’t distinguish signal from noise
- CCM and APCM revenue left on the table because billing and documentation live in different systems
- Programs that never get launched — or never get staffed — because nobody owns design, enrollment, and billing end to end
- No clear evidence, clinical or financial, that the program is working
Beyond Point Solutions:
A Unified Remote Patient Telehealth Platform
TraceWell Health replaces that patchwork with one connected system. Instead of separate contracts and separate logins for RPM, CCM, APCM, telehealth, secure messaging, and care management, you get a single platform where the data feeding clinical decisions is the same data feeding your billing — and every program you run shares one view of each patient.
Operations
One platform for telehealth, secure messaging, RPM, CCM, and APCM — one implementation, one vendor relationship
Workload
AI-driven risk scoring and automated outreach that surface signals instead of adding noise
Revenue
Audit-ready documentation and unified billing tied to the same data your clinicians use
Outcomes
Outcomes measured on every engagement — so you can prove the program works, not just that it’s running
Care Beyond the Four Walls
Care beyond the four walls means care doesn’t stop when a patient walks out of the clinic. TraceWell Health keeps clinical, behavioral, and lifestyle signals flowing in the days, weeks and months between visits, so your care team can act on what’s actually happening in a patient’s daily life — not just what shows up at the next scheduled appointment.
What Is Whole-Person Care?
Whole-person care treats a patient’s clinical, behavioral, and lifestyle data as one connected picture instead of three separate ones. A cardiac patient’s INR readings, a behavioral health patient’s PHQ-9 trend, a weight management patient’s nutrition plan and how closely they’re following it — each tells only part of the story on its own. TraceWell Health’s whole-person care platform brings those signals together on one timeline, built on five pillars:
Ongoing remote monitoring of vitals, INR, cardiac signals, and chronic disease indicators between visits.
Validated instruments (PHQ-9, GAD-7, PCL-5, AUDIT-C, C-SSRS) that surface crisis signals and adherence changes for clinician review.
Nutrition plans built from each patient’s medical history and conditions. Clinicians set the goals and parameters, and Trace Foods generates meal plans, recipes, and shopping lists and captures compliance. Built for chronic disease programs, weight management, and oncology patients gaining weight.
AI-driven risk scoring, automated outreach, tailored care plans, and audit-ready billing documentation.
Every engagement is measured against five categories of results: clinical outcomes, engagement and program fidelity, utilization and cost, operational and financial performance, and patient-reported outcomes. Reported on a regular cadence so leadership, payers, and funders see evidence, not anecdotes.
The intelligence behind our risk scoring is powered by Guardian Alpha’s Intelligence Engine.
Built From Experience, Designed Around Reality
We know what it’s like to run a care program on tools that don’t talk to each other — and to run one that generates plenty of data and no proof. TraceWell Health was built from years inside the operational reality of remote monitoring and care management: the CMS billing rules that shift every year, the alert volume that burns out clinical staff, the readmission math a CFO answers for at every board meeting, the program that stalls because nobody owned enrollment. That’s why the platform is built around unifying programs rather than adding another dashboard, why turnkey services sit alongside the software, and why every engagement is measured against clinical, financial, and patient-reported outcomes. Our promise is simple: every patient connected, every insight actionable, every outcome measured — every day.
RPM, CCM, and APCM — One Connected Care Platform
Here’s the path from where you are today to a running, reimbursed, measured program — on one platform, with as much or as little of our team as you need.
Parts of that path are available as add-on services through the Whole-Person Care Delivery Model.
Design your program with us
Launch and enroll
Run, bill, and measure
Choose How Much of the Path We Walk With You
Every step above is available as an add-on service through the Whole-Person Care Delivery Model. Run the platform yourself, hand us the pieces you don’t have staff for, or let us run the program — the path is the same either way. What you can count on in every model: your clinical protocols, your EHR, your patients’ data in one record, and outcomes reported from day one.
target conditions, eligibility criteria, device mix, reimbursement mapping, staffing model
federal, state, and foundation funding identification and narrative, budget, and outcomes framework
EHR- and claims-based targeting, consent capture, device provisioning, first-reading verification
platform-driven nudges, mood and nutrition check-ins, and human follow-up that keep patients transmitting
licensed nurses and care coordinators who triage alerts and escalate under your approved protocols
clinical, operational, and financial reporting on a regular cadence, with interpretation support
per-patient eligibility tracking, threshold flagging before billing close, and clean claim coordination
What Whole-Person, Connected Care Looks Like in Practice
With TraceWell Health, your care team sees a change in a patient’s status when it happens — not weeks later at the next visit. Your CFO sees CCM and APCM revenue captured instead of leaked through missed days, missed time, or missed codes. Your IT team stops maintaining integrations between five vendors and starts working with one. And leadership sees the proof: outcomes measured across five categories and reported on a schedule, not assembled from anecdotes.
condition-specific biometric trends, guideline-concordant targets, 30-day readmissions, medication adherence
device transmission compliance against CMS thresholds, time-in-program, time-to-intervention
incremental revenue per enrolled patient, staff time versus reimbursement, enrollment and retention
condition-relevant PROMs and patient confidence in self-management
See TraceWell Health on Your Own Data
If you’re ready to see how one connected platform replaces the point solutions you’re currently stitching together — and how the Whole-Person Care Delivery Model fills the staffing gaps in between — request a demo built around your actual patient population, specialty mix, and billing model.
Not ready for a full demo yet? Start with the specific gap most RPM programs miss.
Frequently Asked Questions
What is a remote patient monitoring platform?
A remote patient monitoring platform collects a patient’s vitals and health data between visits and sends it securely to their care team, so changes get caught early instead of at the next scheduled appointment. TraceWell Health is built as one connected platform rather than a standalone device feed.
How do RPM and CCM work together on one platform?
Remote patient monitoring collects data between visits; chronic care management uses that data to coordinate ongoing care and support CMS billing. Running both through one platform — instead of two separate vendor contracts — means the data feeding your care coordination is the same data your billing relies on.
Is TraceWell Health secure and connected to the systems we already use?
Yes. TraceWell Health is HIPAA compliant and SOC 2 Type II certified, and built as a single connected platform — not a bolt-on tool — so patient data moves securely between telehealth, RPM, and care management without separate logins or manual re-entry. It integrates with most major EHRs, so your team keeps working in the systems it already knows.
What does "care beyond the four walls" mean?
It means care doesn’t stop when a patient leaves the clinic. TraceWell Health keeps clinical, behavioral, and lifestyle signals flowing between visits, so care teams can act on what’s happening in a patient’s daily life — not just what shows up at the next appointment.
Why are health systems replacing point solutions with a unified platform?
Running RPM, messaging, and care management through separate vendors means separate contracts, separate logins, and integration work that falls on your IT team. A unified platform like TraceWell Health replaces that patchwork with one connected system.
How does TraceWell Health help reduce hospital readmissions between visits?
TraceWell Health surfaces clinical and behavioral changes in the window between visits — where most preventable readmissions start — so care teams can intervene before a small change becomes an ER visit.
What should health systems look for in an RPM platform?
Look for EHR integration, transparent CMS billing support, evidence the platform reduces alert fatigue rather than adding to it, and a clear plan for how outcomes will be measured — not just device count or price.
How does TraceWell Health handle billing and EHR documentation?
TraceWell Health ties billing and clinical documentation to the same system generating your RPM and care management data, so claims and chart notes don’t require separate manual entry across tools.
What is a whole-person care platform?
A whole-person care platform connects clinical, behavioral, and lifestyle signals in one system, instead of treating each as a separate data source. TraceWell Health is built around this idea — one platform, one view of the patient, across every program you run.
What is Trace Foods?
Trace Foods is TraceWell Health’s personalized nutrition product. It takes a patient’s medical history and conditions into account, lets the clinician set goals and parameters, and then generates meal plans, recipes, and shopping lists, with a way to capture compliance. It is part of the Whole Person Health Platform, alongside Trace Moods behavioral health signals.