ElderberryMD

Concierge Care Coordination at Scale

Reduce readmissions, improve HCAHPS scores, capture CCM revenue, and give every patient the coordinated care experience that drives loyalty and outcomes.

The Coordination Problem at System Scale

Readmission Penalties

CMS penalizes hospitals for excess readmissions. The #1 driver? Poor transition-of-care coordination. Patients leave the hospital without clear follow-up plans, miss appointments, and end up back in the ER.

Patient Satisfaction

HCAHPS scores directly impact reimbursement. Patients who feel coordinated and cared for rate their experience higher. Patients who fall through the cracks between departments don't come back — or they come back through the ER.

Revenue Left on the Table

Your system has thousands of patients eligible for Medicare CCM, PCM, and BHI billing. Without infrastructure to deliver and document coordination services, that revenue goes uncaptured.

What ElderberryMD Brings to Your System

Transition of Care

We coordinate the post-discharge journey. Follow-up appointments get scheduled. Medications get filled. Home health gets arranged. Primary care gets notified. We don't let patients fall through the cracks.

Chronic Care Coordination

For your highest-utilization patients, we provide ongoing concierge-level coordination across all their providers within and outside your system. We make the calls, handle logistics, and keep everyone aligned.

Patient Navigation

Large health systems are hard to navigate. We guide patients to the right department, the right specialist, the right program. We book their appointments and prep them for every visit.

Medicare Revenue Capture

We provide the coordination services and documentation needed to bill CCM ($62-93/patient/month), PCM ($83-115), and BHI ($120-175). At scale, this is significant new revenue.

Referral Loop Closure

Internal and external referrals that go unscheduled are lost revenue and worse outcomes. We track every referral, schedule the appointment, and close the loop.

Patient Retention

Patients who feel coordinated and cared for stay in your system. They don't seek care elsewhere. They refer friends and family. Concierge coordination builds loyalty.

Impact at System Scale

20-30%
Readmission reduction with active transition coordination
$500K+
Annual CCM revenue per 500 enrolled patients
40%
Of referrals go unscheduled without coordination
15+ pts
HCAHPS improvement with care coordination programs

Enterprise-Ready Integration

EHR Integration

  • FHIR R4 native
  • Epic, Cerner, Athenahealth, MEDITECH
  • ADT feeds for real-time discharge alerts
  • Bi-directional data exchange

Compliance & Security

  • HIPAA compliant with BAA
  • HITRUST framework
  • HL7 v2 / CDA support
  • Role-based access controls

Implementation Path

Discovery

We analyze your patient population, identify high-impact cohorts, and map integration requirements with your EHR and existing programs.

Pilot

Start with a focused cohort — post-discharge, high-utilization, or CCM-eligible. Prove the model with measurable outcomes in 90 days.

Scale

Expand across departments, service lines, and patient populations. Add referral coordination, chronic care, and Medicare billing.

Optimize

Continuous improvement based on outcomes data. Quarterly business reviews. Expanding to new use cases and populations.

Let's Build a Pilot

We'll work with your team to identify the highest-impact cohort and design a 90-day pilot with clear success metrics.

Schedule a Conversation

Or email us: [email protected]