Medicare is funding care that keeps your sickest patients out of the hospital, and most practices are leaving that money on the table. Rachel Yates, a nurse and health care executive who runs a nurse-led care coordination service, breaks down two codes CMS built in 2024 that almost no one is using. The patients who qualify are the ones you already see every day, and right now they are paying for a problem that was never theirs.

⏱️ Chapters:
0:00 Introduction
0:33 The nurse who started building before the credentials
1:35 Two funded codes almost no practice uses
3:03 Why documentation alone fails the patient
5:03 Coordination was never the question, delivery was
5:46 What a real coordination call sounds like
7:32 The medication mistake a phone call caught
8:38 Why your existing staff cannot absorb this
10:31 The reimbursement Medicare keeps growing while others get cut
11:09 The patients you are missing this for
14:09 Take home messages

About this episode:
Rachel Yates is a trauma and surgical ICU nurse turned health care executive who runs a nurse-led service delivering the Community Health Integration and Principal Illness Navigation codes CMS introduced in 2024. She argues that these are not billing add-ons but real clinical care, funded reimbursement any practice can deliver today for patients they already see. Two years in, most practices still are not using them, and she pins the gap on education, not effort, since many assume their existing chronic care management already covers it. She draws a sharp line between coordination companies that only log calls and check boxes and a model where every patient has a named nurse acting on problems in real time, so an issue is already worked by the next visit rather than just charted. She points to a decade of evidence that coordination reduces readmissions, walks through the higher time and documentation demands that make in-house delivery impractical, and shares a case where explaining a confusing medication label likely prevented a readmission. She closes on the human stakes, the daughter navigating a parent's brand-new dementia diagnosis alone and the COPD patient who keeps landing back in the hospital because nobody caught things early. Her core message is that Medicare wants to pay practices to keep these patients well, and the ones missing out are the ones who need it most.

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