Glenn County Rural Hypertension Continuum — a practical RPM opportunity for local clinics.
A team of Glenn County partners is preparing a California Rural Health Transformation (Track 2) application to fund a simple, low-burden remote patient monitoring program for hypertension. This page is for clinic leadership deciding whether to add a short letter of support.
Why clinics may like this model
The program is built to add remote monitoring without adding routine work. Patients get automated guidance; staff see only the cases the protocol flags.
The app handles the routine work
Automated triage, bilingual education, and titration reminders mean patients are supported between visits without staff chasing readings. Clinicians and MAs only engage when the alert queue surfaces a case that needs a human decision.
No upfront cost, low ongoing fee
Grant funds cover technology, training, and starter BP cuffs. After that, participating clinics pay roughly $5 per enrolled patient per month — a fee designed to be offset by staff time saved and, for eligible Medicare patients, RPM reimbursement.
Evidence-based without extra documentation
Escalation logic follows ACC/AHA 2017 guidance; titration follows the UC Way algorithm. Providers get a triaged queue, a copy-ready SOAP draft, and an end-of-month billing summary — not open-ended monitoring notes.
Sign a brief letter of support — that is the whole ask right now.
If the grant is awarded, participating clinics would manage their own paneled hypertensive patients using the RPM program. The grant covers the technology, training, and starter equipment. Concretely, participation would look like:
- Sign a brief letter of support to be included in the CalRHT application
- Receive training for staff and providers on how to use and bill for RPM services
- Identify eligible hypertensive patients on your existing panel
- Assist with patient enrollment and initial device setup — some BP monitors provided at no cost
- Use RPM data and alerts to guide follow-up between visits
- Continue normal clinical oversight within the patient's medical home
Bottom line for the clinic
A low-burden, low-overhead program. It brings evidence-based hypertension monitoring to Glenn County at no upfront cost, with automated triage and education that keep clinicians and MAs focused on patients who actually need a decision — while creating a sustainable monthly reimbursement opportunity for Medicare patients who actively transmit readings.
The two-part continuum
The proposal splits the county's hypertension work into two complementary tracks so clinics can focus on the patients they already know best.
Clinic RPM — your own patients
Clinics manage the hypertensive patients on their existing panel. The grant provides full app access, staff and provider training, and starter Bluetooth/Wi-Fi BP cuffs for the first enrolled patients. Care stays inside the medical home; the app just adds the between-visit layer.
This page is about this track.
Direct-access safety net (TCCAP)
A separate, capitated, direct-access subscription for uninsured, underinsured, and Medi-Cal-transition residents, delivered by North State Prevention through the local non-profit TCCAP with Enloe as clinical hub. Includes a grant-funded Wi-Fi cuff, a telehealth visit, RPM, annual labs at discounted institutional rates, and 90-day generic medication shipments through Rx Outreach.
Baseline pricing: ~$11/mo (2-drug regimen) or ~$18/mo (3-drug regimen), plus a one-time setup fee — see full breakdown below.
Who else is at the table
The program is intentionally collaborative. Each partner contributes a specific capability so clinics are not asked to carry the community-outreach, technology, or uninsured-track work alone.
Glenn County Public Health
Project lead
Governance, clinical model development, oversight, and partner coordination. Dr. Garrison leads RPM application development as a Public Health employee, supported by digital transformation consultant John Meyer, plus IT and legal support for testing, cybersecurity, privacy, and compliance.
TCCAP
Community implementation partner
Day-to-day implementation, recruitment, enrollment, and CHW services — outreach, eligibility, device training, troubleshooting, adherence support, and barrier navigation.
Participating primary-care clinics
Clinical pathway for insured patients
Glenn Family Practice, Family Care Clinic, Orland First Care, Northern Valley Indian Health, and Orland Medical Clinic. One additional local clinic is in discussion.
Northern Valley Indian Health
Tribal access pathway
Reservation access and a designated physician assistant to help oversee the project, focused on patients who have been difficult to manage.
Enloe Medical Center
Uninsured-track clinical hub
Remote clinical oversight and telehealth-based care for uninsured residents, with TCCAP CHW support.
UC Davis
Clinical consultation
Consultation on the application's decision logic and evidence-based hypertension pathways.
Partnership HealthPlan of California
Coverage transition support
Referrals and information on members losing Medi-Cal coverage, reducing gaps during transitions.
Direct-access safety-net pricing for the uninsured cohort
Handled separately from your clinic panel through North State Prevention + TCCAP + Enloe. The subscription bundles the yearly telehealth visit, annual labs at discounted institutional rates, and 90-day generic med shipments from Rx Outreach.
| Item | Cost | Notes |
|---|---|---|
| Annual telehealth provider visit | $60/yr (~$5/mo) | Included in program |
| Annual lab panel (CMP + UACR) | $30/yr (~$2.50/mo) | ~$15 wholesale + $15 draw/supply via TCCAP partnership |
| Lisinopril/HCTZ single-pill combo | $40/yr (~$3.50/mo) | 90-day fills via Rx Outreach mail pharmacy |
| + Amlodipine (Step 3a/3b add-on, if needed) | +$88/yr (~$7.50/mo) | Same mail pharmacy |
| One-time onboarding: CHW enrollment visit + BP cuff | TBD | CHW rate pending; cuff cost partially offset by CalRHT grant |
~$15/mo
2-drug regimen
Flat subscription: yearly telehealth visit + yearly labs + lisinopril/HCTZ combo. BP monitor and initial intake billed separately.
~$20/mo
3-drug regimen (adds amlodipine)
Same bundle with amlodipine added. BP monitor and initial intake billed separately.
Monthly price is a flat subscription covering the annual provider visit, annual labs (wholesale TCCAP rates + $15 draw fee), and the mail-order medication(s). Not included: a one-time BP monitor (~$50 Bluetooth cuff at bulk) and the initial CHW intake / enrollment visit — both partially offset by the CalRHT grant during the pilot.
Why this may matter financially — 2026 RPM device codes
For Medicare patients, RPM includes clear device-based billing codes that do not require stopwatch-style time tracking inside the application. The 2026 CMS Physician Fee Schedule introduced a new code (99445) that reimburses at the full device rate for months when a patient transmits just 2–15 days — closing a gap that historically made partially-adherent months unbillable.
| CPT | Description | 2026 rate |
|---|---|---|
| 99453 | Setup and patient education | $21.71 (one time) |
| 99445NEW 2026 | Device supply and data transmission, 2–15 days/month | $52.11 /mo |
| 99454 | Device supply and data transmission, 16–30 days/month | $52.11 /mo |
~$5,211
/ month recurring
100 Medicare patients × $52.11 (99445 or 99454). Any patient logging ≥2 transmission days bills the full device rate.
~$62,532
/ year recurring
Annualized device revenue on a 100-patient Medicare panel. Scales linearly with panel size.
~$2,171
one-time setup
99453 across the initial 100-patient cohort. Billed once per patient at enrollment.
Important for FQHCs and RHCs in Glenn County
Public 2026 CMS guidance indicates that FQHCs and RHCs now bill individual RPM CPT codes rather than the old G0511 bundle, and that CPT 99445 is covered for FQHCs and RHCs retroactive to January 1, 2026 after CMS confirmed its initial omission was accidental. This is a meaningful shift — historically, RPM revenue in RHC/FQHC settings was capped by the bundled rate.
California payer note. Medicare is the clearest reimbursement pathway. California Medi-Cal and managed care plans, including Partnership HealthPlan, may also reimburse remote monitoring and telehealth-related services, but clinics should confirm exact code-level payment through their billing teams and payer contacts before projecting non-Medicare revenue.
Time-based management codes (99457, 99458) are intentionally excluded from this pitch. The whole point of the program is that the app automates the 20-minute-per-patient monitoring work those codes reimburse. Clinics would only bill them if staff performed additional documented review time beyond the app-driven workflow — that would be additive revenue, not baseline.
Rates shown are estimated 2026 CMS national non-facility averages. Region and MAC vary — verify against the CMS Physician Fee Schedule lookup.
Try the prototype
Open either side. All data is synthetic; nothing leaves your browser. Both demos are pre-loaded with patients across every escalation state — controlled, escalating, non-adherent, newly enrolled, and recovered.
Next step
CalRHT timing is short. If your clinic is open to being included, a brief letter of support is enough to lock the partnership structure so the grant narrative can be finalized. Reach out directly: