Outreach and ongoing care
Patient calls, enrollment support, and follow-up on the care-plan steps your team identifies.
For rural providers & networks
Your extended care team.
Across the miles.
MySeema brings the trained staff, day-to-day management, and follow-through to extend your rural care team. We handle patient outreach, care navigation, and care-management coordination, so you do not need to hire or run a separate navigation team. Your clinicians keep medical decisions.
Support for the people your team serves.
For rural hospitals and critical access hospitals, rural health clinics, community health centers and FQHCs, and ACOs or regional networks. We welcome organizational partnerships in all 50 states and define the work around your team and community.
Referrals and remote appointments
Help coordinate specialist appointments, records, and visit preparation, including telehealth when appropriate.
Remote monitoring support
Coordinate the agreed monitoring workflow, with responsibility for reviewing readings and responding to concerns defined before launch.
After a hospital stay
Help arrange follow-up appointments, carry practical next steps forward, and route medication questions to the clinical team.
Refills and care-plan steps
Follow up on refill requests, ordered tests, and other arrangements. Clinicians authorize prescriptions and treatment.
Travel and local resources
Help coordinate transportation and connections to available community resources; keep unresolved barriers visible to your team.
Our team carries the follow-through
We take on the work between visits.
MySeema as your extended team
We reach out
Our navigators proactively contact patients in your program, identify coordination needs, and follow up on care-plan steps.
We coordinate
We arrange appointments, follow up on referrals and records, and help with refill requests, travel, and other practical needs.
We follow through
We carry forward clinician-directed next steps, follow up with patients, and document progress or unresolved barriers in the agreed record.
Your clinicians keep clinical decisions. When a concern requires medical judgment, we bring it to the appropriate clinician and coordinate the next step. MySeema manages the day-to-day navigation work.
Our team manages outreach, coordination, and documentation within the agreed program. We coordinate record access and communication arrangements with your team during setup.
Fit the service to your community.
More capacity. No new navigation hires.
We supply and manage the navigators and daily coordination, extending your nurses, care managers, and community partners. Your clinicians retain clinical assessment, prescribing, treatment decisions, and oversight.
We adapt to your community.
Routine outreach can start with a phone call. We agree the calling introduction with your clinic and plan any video or monitoring support around the patient’s devices and connectivity. MySeema documents the agreed work in your existing record workflow.
HHS identifies connectivity, travel, specialty access, and staffing as considerations in rural telehealth planning. Read the rural workflow guidance →
Experience working alongside Louisiana physicians.
Ross Hamic, MD
The Family Doctors · Shreveport, Louisiana
“MySeema has done an exceptional job at initiating and streamlining CCM and integrating with our clinic.”
An excerpt from a physician’s partnership experience, not a rural-hospital outcome study.
We bring the team and lead the setup.
We map the program
We work with you to identify the patient population, clinical priorities, and coordination our team will handle.
We staff and organize the work
We bring the navigators and manage their daily work. We coordinate record access and agree clinical review, coverage, and payment arrangements with your team.
We run the follow-through
We handle outreach, coordination, and documentation, and report care touches, care-plan activity, follow-up actions, and clinical escalations.
Facility type, payer, patient eligibility, and the services delivered affect billing. We review these with your team before launch.
See our partnership and reporting approach →Policy context
Planning a rural health transformation project?
CMS’s Rural Health Transformation Program supports state-led work on chronic disease, rural workforce, regional coordination, and remote-care technology. Explore the CMS program →
Tell us which patients need support and which follow-up tasks your team needs help completing. We can discuss a service scope with your organization. Funding eligibility and purchasing requirements depend on the state and project; a MySeema partnership does not establish grant eligibility or CMS endorsement.
Questions from rural executives and clinicians
Do we need to hire or manage a navigation team?
No. MySeema supplies the navigators and manages their day-to-day coordination work. Your team provides the agreed record access, clinical direction, and decisions that require medical judgment. We lead setup and keep the work visible through documentation and reporting.
Do we need a new telehealth platform?
MySeema’s role is the navigation and care-management work around your patients. We agree how to use your existing systems and the treating team’s telehealth arrangements. Access and any integration requirements are reviewed before launch.
Does MySeema provide the specialist consultation?
The treating clinician provides the consultation and makes clinical decisions. MySeema can help with referral coordination, appointments, records, and the next steps around that care.
How does remote patient monitoring fit?
RPM can be part of the agreed program when clinically appropriate. Device support, review of readings, and escalation responsibilities must be defined. It is not a promise of continuous emergency monitoring. CMS explains RPM →
Is billing the same for a rural clinic and a hospital?
No. RHCs, FQHCs, critical access hospitals, and physician practices have distinct payment arrangements. The billing entity, patient eligibility, payer, and actual services matter. We define the proposed arrangement with your team rather than promise one reimbursement figure. CMS RHC and FQHC guidance →
Can an RHT-funded project work with MySeema?
We can discuss the navigation and care-management scope your organization needs. The state or funding recipient determines allowable costs, procurement, and reporting requirements. Any funded arrangement must be reviewed against those requirements.
Is this the same as CMS ACCESS?
No. ACCESS is a separate CMS model with its own participation and payment rules. Any proposed MySeema role would require a separate review. This page does not represent MySeema as an ACCESS participant. Read about ACCESS →
Can you support rural oncology pathways?
Yes. We can define navigation around the participating oncology team, local practice, patient, and family. This can include appointments, records, practical arrangements, and follow-through under the care team’s protocols.
Extend your team without building another one.
Tell us about your organization. We’ll outline the work our team can take on and lead the setup around your patients and clinical model.
Sources and program guidance
Policy sources reviewed September 9, 2026. These sources describe public programs and clinical workflows, not MySeema outcomes or endorsements.