Services and Tracks
ACCESS services organized around real patient follow-through
New York Pulmonary Care ACCESS Model matches eligible Original Medicare patients to the appropriate ACCESS track and organizes education, coaching, medication support, monitoring when appropriate, and care-team communication around the patient's needs.
ACCESS care support
Device visibility, outreach, and clinician coordination between visits
Care Team
800-745-1444Office hours: Monday - Friday, 8:00 AM - 5:00 PM
ACCESS Model accepted applicant. Final participation remains subject to CMS requirements and Participation Agreement execution.
How services are organized
This is not a one-size-fits-all service menu. Each support step is tied to eligibility, track review, and care-team coordination.
Patients should understand what they qualify for, what support they receive, who is following up, and how their existing doctors stay part of the care picture when appropriate.
Matched to the Right Track
The care team checks the patient's qualifying condition, Original Medicare status, service area, consent, and program requirements before services begin.
Built Around Follow-Through
Education, monitoring, medication support, coaching, and communication are organized around what the patient needs after the visit.
Monitoring When Appropriate
Connected devices and remote readings are used only when clinically appropriate and consistent with ACCESS program requirements.
Patient Rights Protected
ACCESS support does not replace Original Medicare, regular doctors, emergency care, or the patient's right to see any Medicare provider.
ACCESS Tracks
The care team confirms the right track during enrollment review based on the patient's qualifying condition, service area, and CMS program requirements.
eCKM / CKM
Cardio-Kidney-Metabolic Support
Care support for eligible Original Medicare patients with cardio-kidney-metabolic needs. eCKM may include hypertension, or two or more of dyslipidemia, obesity or overweight with a central obesity marker, and prediabetes. CKM may include diabetes, chronic kidney disease stage 3a or 3b, or atherosclerotic cardiovascular disease.
MSK
Musculoskeletal Support
Support for eligible Original Medicare patients with chronic musculoskeletal pain through education, coaching, tracking, and clinician support.
BH
Behavioral Health Support
Support for eligible Original Medicare patients with depression or anxiety, including check-ins, education, and care coordination when appropriate.
Included Services
Nutrition Support
Guidance to support eating habits related to the patient's care plan.
Activity Coaching
Support with safe movement and activity goals when appropriate.
Behavioral Health Support
Support for emotional and behavioral health needs as part of the care program.
Remote Monitoring
Connected devices may help the care team monitor health information between visits.
Medication Support
Medication review and support to help patients follow their care plan.
Clinician Communication
Patients and clinicians may communicate with the care team about program-related needs.
Education
Plain-language information to help patients understand their condition and care steps.
Community Resource Support
Help identifying services such as food, housing, or transportation support when needed.