In my years as an ICU nurse, I learned to recognize a pattern. The patients I cared for in trauma surgical intensive care often arrived after a cascade of preventable events. A missed medication. A symptom that went unaddressed. A follow-up appointment that never happened. By the time they reached my unit, the question was no longer how to keep them well at home. It was how to bring them back from the edge.

What struck me most wasn’t the acuity. It was the predictability. The same patients with the same chronic conditions, decompensating in the same patterns, year after year. Heart failure. Diabetes. COPD. Dementia. Cancer. The illnesses themselves were complex, but the trajectory was strikingly consistent: a primary care visit, a referral, a series of missed connections and eventually, a hospital admission.

The fix isn’t mysterious. It’s coordination. Someone tracking medications. Someone checking in between visits. Someone identifying social barriers (transportation, food, housing) that quietly destabilize even well-treated chronic disease. Someone watching for the warning signs before they become emergencies.

And here is what most patients, and many clinicians, do not yet know: As of January 2024, Medicare pays for exactly that kind of care.

In the 2024 Physician Fee Schedule, the Centers for Medicare and Medicaid Services (CMS) introduced two new categories of reimbursement: Community Health Integration, which funds care coordination addressing health-related social needs, and Principal Illness Navigation, which funds navigation services for patients with serious, high-risk illness. These are not pilot programs. They are not theoretical. They are reimbursable services that primary care practices can deliver today, for patients who already qualify, paid for by Medicare under existing law.

Two years later, most practices have not operationalized them.

The reasons are practical, not ideological. Awareness is uneven. Workflows have to be redesigned. Documentation requirements are specific. Most practices already operate on thin margins with stretched staff. Adding new categories of clinical work, even reimbursable ones, requires infrastructure most small practices do not currently have.

The result is a gap between what Medicare authorizes and what patients actually receive. The federal funding exists. The patients exist. The clinical work that would help them exists. What is missing is the operational layer connecting the three. And that gap is not abstract. It plays out in real lives every day.

It plays out in the elderly patient with congestive heart failure who runs out of her diuretic on a Friday afternoon and ends up in the emergency department by Monday because no one was watching her medication refills. It plays out in the patient with cancer navigating treatment alone because no one helped him understand the appointments, the side effects, or the questions to ask his oncologist. It plays out in the patient with diabetes whose social isolation is quietly undermining every clinical intervention his physician makes, because nothing in a 15-minute visit can address loneliness or food insecurity and nothing currently funds the time to try.

What CMS recognized in 2024 is that medicine is not only what happens in the exam room. It is what happens in the days and weeks between visits. It is whether a patient can get to the pharmacy. Whether she understands her discharge instructions. Whether someone is available when something changes, before the change becomes a crisis. The new codes were a quiet acknowledgment, by the federal government itself, that the visit-centric model of primary care has been inadequate for chronically ill patients for a long time and that the work of coordination is real clinical work deserving of real reimbursement.

The codes will not fix American health care. No single policy change does. But they represent something rare: a federal recognition that the gap exists, paired with funding designed specifically to close it. The longer we treat that funding as billing trivia, rather than as the clinical infrastructure it was meant to be, the more patients will continue paying the price for fragmentation that was never theirs to fix.

I left the bedside to build a company that helps independent practices deliver coordinated care for the patients these new codes were designed to serve. I did not leave because clinical work is unimportant. I left because the patients I cared for in the ICU should not have been there in the first place. Most of them did not need more heroic medicine. They needed someone watching, between the visits, while they were still well enough to be helped.

That work has now been authorized. It has been funded. It is sitting in front of every primary care practice in the country, waiting to be picked up.

The question is no longer whether the system will pay for coordination. It will. The question is whether we, as clinicians, will recognize coordination as the clinical work it has always been, and finally build the infrastructure to deliver it.

The patients have been waiting longer than they should have to.

Rachel Yates is a registered nurse with nearly a decade of clinical experience, including trauma surgical ICU and virtual nursing. She earned her Bachelor of Science in Nursing from Purdue University Northwest and is completing her Master of Science in Nursing in executive nurse leadership at Purdue University Global, where she was inducted into Alpha Alpha Alpha, the national honor society for first-generation college students.

She is the founder and chief executive officer of Premier Care Coordination, a nurse-led virtual care coordination company based in Gary, Indiana. The company partners with primary care practices to deliver Medicare community health integration, principal illness navigation services, and chronic care management.

Rachel has written in Medical Economics on how new Medicare care coordination codes could transform care for vulnerable patients and is a recognized voice on the gap between federal health care policy and practice-level implementation. She shares professional updates on LinkedIn, with company updates available through Premier Care Coordination on LinkedIn.