Cares for CaregiversA trusted partner for your patients after they leave the hospital.
Refer your Medicare patients to Altitude Cares for transition-of-care and chronic care management. Our clinical team coordinates the discharge, supports the family, and follows up for months — at no cost to most patients.
Medicare & Medicaid covered · Statewide in Indiana
When to refer
You can't be everywhere. We can help.
Altitude Cares extends your team into the home. We pick up where the hospital visit ends — coordinating care, monitoring conditions, and supporting the family — so your patients stay on track and out of the ED.
- Your patient is being discharged with a complex regimen and no one at home is ready.
- You're worried about a readmission within 30 days — but you can't call every week.
- The family caregiver is overwhelmed and needs a real person to talk to.
- Your patient has multiple chronic conditions that need ongoing monitoring between visits.
Programs you can refer to
Medicare-covered. Usually no cost to the patient.
Three ways to extend support to your patients and their families across Indiana.
Transition of Care Management (TCM)
Medicare-covered support for the 30 days after discharge from a hospital, SNF, or observation stay. We handle the post-discharge call, medication reconciliation, follow-up coordination, and red-flag monitoring.
- Eligible: Medicare beneficiaries discharged to a community setting
- Coordinated with the patient's PCP and specialists
- Helps reduce 30-day readmissions
Chronic Care Management (CCM)
Medicare-covered monthly care management for patients with two or more chronic conditions. Our team provides ongoing check-ins, medication oversight, and care plan updates between office visits.
- Eligible: Medicare patients with 2+ chronic conditions
- Typically no cost to dual-eligible patients
- Documentation shared back with the referring provider
Caregiver Support Line
A free line for the family member doing the caregiving. Open to any Indiana caregiver — no enrollment required. Great to hand to families when your patient isn't a fit for TCM or CCM.
- Open to any Indiana caregiver
- Discharge planning, resources, and care coordination
- No cost, no insurance required
Coverage & cost
Covered by Medicare. Built for your panel.
Our transition-of-care and chronic care management programs bill under standard Medicare CPT codes. For most patients — especially those who are dual-eligible — there is no out-of-pocket cost.
Your patient stays your patient. We coordinate with you, not around you. Care plans, medication changes, and red flags are documented and shared back with the referring provider.
Medicare & Medicaid covered
TCM and CCM are reimbursed by Medicare; most dual-eligible patients pay nothing.
Clinical team, in your community
Indiana-based nurses and care coordinators who know the local hospitals, SNFs, and home health agencies.
Family included
Caregivers can call our support line anytime, even if your patient isn't enrolled in a program.
How to refer
Three steps. No paperwork mountain.
Call or join the network
Call our line, fax a referral, or send via your EHR. We accept referrals from PCPs, hospitalists, case managers, and discharge planners.
We reach out to the patient
Our team contacts the patient and family within one business day to introduce the program, confirm eligibility, and obtain consent.
You stay in the loop
We share the care plan, medication reconciliation, and any escalations back to you. Your panel, your care decisions.
Provider referral form
Tell us a bit about your practice and join our priority referral network.
Frequently asked
Provider questions, answered.
Ready to refer a patient? Let's talk.
Call to set up referrals for your practice or hospital team. We'll make it as simple as possible to plug into your existing workflow.
Medicare & Medicaid covered · Indiana