Robert Martinez
RPM
CCM
93% Adherence
Urgent Escalation
RPM Chart
Jan 1-31, 2025
Days Monitored
28/31
Glucose Avg
142 mg/dL
BP Avg
135/82
Compliance
95%
Glucose trending down with new regimen. BP slightly elevated.
CCM Chart
Jan 1-31, 2025
Total Time
45 min
Interactions
4 calls
Last Contact
01/20/25
Medication reconciliation completed. Discussed lifestyle modifications.
View Complete Patient Data
Demographics
Date of Birth
05/15/1978
Age
45 years
Gender
Male
Primary Language
English
Insurance
Primary Insurance
Blue Cross Blue Shield
Member ID
XYZ123456789
Group Number
98765
Coverage Type
PPO
Primary Diagnoses
Type 2 Diabetes
E11.9
Essential Hypertension
I10
Hyperlipidemia
E78.5
Current Medications
Metformin HCl
1000mg twice daily • Last fill: 01/05/2025
Lisinopril
10mg once daily • Last fill: 12/28/2024
Atorvastatin
40mg once daily at bedtime • Last fill: 01/10/2025
Recent Lab Results
HbA1c
7.2%
Above target
Total Cholesterol
218 mg/dL
Borderline high
eGFR
68 mL/min
Normal
LDL Cholesterol
142 mg/dL
Above target
Known Allergies
Penicillin - Rash
Sulfa drugs - Hives
Aspirin - GI upset
Blood Glucose Management
- • Daily glucose monitoring via RPM device
- • Weekly pharmacist consultation for medication optimization
- • Monthly HbA1c trend analysis
- • Nutrition counseling and meal planning
Hypertension Control
- • Twice-daily BP monitoring
- • Medication adherence tracking
- • Lifestyle modification counseling
- • Sodium restriction education
Care Team
Primary Care Provider
Dr. Michael Roberts
Clinical Pharmacist
Dr. Sarah Johnson
Care Coordinator
Jennifer Smith, RN
Last Review
01/15/2025
Medication Adjustment - Metformin
01/15/2025
Increased Metformin from 500mg to 1000mg twice daily due to persistent elevated glucose levels. Patient tolerating well with no GI side effects.
RPM Device Setup
01/10/2025
Patient enrolled in RPM program. Glucose monitor and BP cuff provided. Initial training completed. Patient demonstrated proper use of devices.
Initial CCM Assessment
01/05/2025
Comprehensive medication review completed. Identified potential drug interactions. Created care plan focusing on diabetes and hypertension management.
Lab Results Review
01/02/2025
HbA1c elevated at 7.2%. LDL cholesterol above target at 142 mg/dL. Discussed intensification of therapy with PCP. Patient agreeable to medication changes.
RPM Device Data - Smart Cap (Medication Adherence)
Online
Last reading: 2 hours ago
93%
Overall Adherence
↑ 2% this week
28
Days Monitored
Since Jan 1st
2
Missed Doses
Last 30 days
8:30 AM
Avg Dose Time
±15 minutes
Medication Adherence Details
Metformin HCl
500mg • Twice daily • Morning & Evening
Lisinopril
10mg • Once daily • Morning
Atorvastatin
20mg • Once daily • Evening
Recent Dose History
Date
Time
Medication
Status
Notes
Jan 23, 2025
8:32 AM
Metformin, Lisinopril
Taken
On time
Jan 22, 2025
8:28 AM
Metformin, Lisinopril
Taken
On time
Jan 22, 2025
7:45 PM
Atorvastatin
Missed
Patient forgot
Jan 21, 2025
8:35 AM
Metformin, Lisinopril
Taken
On time
Emily Chen
CCM
78% Adherence
New
CCM Chart
Jan 1-31, 2025
Total Time
38 min
Interactions
3 calls
HbA1c
8.1%
Missed Doses
6 this mo.
Adherence challenges due to work schedule. Implemented reminder system. Scheduled nutrition consult.
View Complete Patient Data
Demographics
Date of Birth
12/03/1985
Age
39 years
Gender
Female
Primary Language
English
Primary Diagnoses
Type 2 Diabetes
E11.9
Depression
F32.1
Current Medications
Glipizide
5mg twice daily • Last fill: 01/08/2025
Sertraline
50mg once daily • Last fill: 01/12/2025
Recent Lab Results
HbA1c
8.1%
Above target
Fasting Glucose
165 mg/dL
Above target
Known Allergies
None documented
Diabetes Management & Adherence
- • Implement medication reminder system
- • Weekly check-ins to address adherence barriers
- • Nutrition consultation scheduled
- • Blood glucose monitoring education
Mental Health Support
- • Monitor antidepressant effectiveness
- • Coordinate with mental health provider
- • Address depression impact on self-care
- • Provide emotional support during calls
Care Team
Primary Care Provider
Dr. Lisa Wang
Clinical Pharmacist
Dr. Sarah Johnson
Mental Health Provider
Dr. Jennifer Adams, PsyD
Last Review
01/18/2025
Adherence Intervention
01/18/2025
Implemented medication reminder system due to missed doses. Patient reports work schedule conflicts. Scheduled nutrition consultation to address dietary challenges.
CCM Enrollment
01/12/2025
Patient enrolled in CCM program. Initial assessment revealed depression affecting medication adherence. Coordinated with mental health provider for integrated care.
Medication Review
01/08/2025
Comprehensive medication review completed. Identified potential interaction between Glipizide and Sertraline. Adjusted timing of medications to minimize interaction.
Initial Assessment
01/05/2025
Patient referred for CCM due to poor diabetes control and depression. HbA1c elevated at 8.1%. Created care plan focusing on adherence and mental health support.
CCM Device Data - Weight Scale
Online
Last reading: 1 day ago
78%
Overall Adherence
↓ 5% this week
18
Days Monitored
Since Jan 12th
6
Missed Readings
Last 30 days
7:15 AM
Avg Reading Time
±30 minutes
Weight Trend Analysis
Current Weight
185.2 lbs
Starting Weight
187.3 lbs
Target Weight
170.0 lbs
Recent Weight Readings
Date
Time
Weight
BMI
Status
Jan 22, 2025
7:30 AM
185.2 lbs
28.4
Good
Jan 21, 2025
7:45 AM
186.1 lbs
28.6
Good
Jan 20, 2025
--
--
--
Missed
Jan 19, 2025
8:15 AM
185.8 lbs
28.5
Good
James Wilson
RPM
RTM
100% Adherence
RPM Chart
Jan 1-31, 2025
Days Monitored
31/31
BP Avg
118/72
HR Avg
72 bpm
Weight
Stable
Exceptional compliance. Post-cardiac event monitoring shows stable vitals.
RTM Chart
Jan 1-31, 2025
Days Tracked
28/31
INR Avg
2.5
In Range
96%
Warfarin therapy stable. INR consistently in therapeutic range.
Maria Rodriguez
RTM
88% Adherence
RTM Chart - Asthma Management
Jan 1-31, 2025
Peak Flow Avg
380 L/min
Inhaler Use
2x daily
Rescue Use
3 times
Symptom-free Days
26/31
Well-controlled asthma. Minimal rescue inhaler use. Continue current regimen.
David Thompson
CCM
RPM
95% Adherence
RPM Chart - Heart Failure
Jan 1-31, 2025
Weight Change
-3 lbs
BP Avg
128/78
Daily Weights
30/31
Edema
None
Stable weight with appropriate diuresis. No signs of decompensation.
CCM Chart
Jan 1-31, 2025
Total Time
52 min
Interactions
5 calls
Sodium Intake
< 2g/day
Excellent dietary compliance. Fluid restriction maintained. Caregiver engaged.