The conditions our calls keep an eye on between visits.
We start with the chronic conditions that drive the most avoidable hospital stays in high-risk Medicare populations. For each one, the check-in call keeps an ear out for the everyday signs that someone is heading the wrong way — and gets the urgent ones to a clinician fast.
- HIPAA-compliant
- BAA-ready
- CPT 99490-native
- Transparent AI
Conditions covered
One signed-off workflow behind each.
- Heart failureCovered
- COPDCovered
- Type 2 diabetesCovered
- HypertensionCovered
- Coronary artery diseaseCovered
- Atrial fibrillationCovered
Six conditions we build around first.
One workflow per condition, each describing the topics a check-in should cover. We keep the description here high-level on purpose — the exact questions and the lines we draw stay inside the product.
Heart failure
Keeps an ear out for breathing, swelling, and weight changes — the everyday signs that someone with heart failure is starting to hold onto fluid.
COPD
Listens for shortness of breath, cough, and changes in how much the day takes out of someone — the early signs of a flare-up.
Type 2 diabetes
Checks in on how someone is feeling day to day, whether medications are going as planned, and the symptoms that come with blood sugar running high or low.
Hypertension
Keeps an eye on how someone is doing on their blood-pressure routine and the symptoms worth mentioning between readings.
Coronary artery disease
Listens for chest discomfort, breathlessness, and changes in what someone can do without tiring — and treats anything that sounds like an emergency as one.
Atrial fibrillation
Checks in on palpitations, dizziness, and energy levels, and how someone is getting on with the medications that go with an irregular heartbeat.
Each line above is the gist, not the script. What a call actually asks — and where the line sits for what counts as a concern — is clinical content your supervising physician owns and can move.
Your panel isn't only six conditions.
The core set is where we start, not where we stop. We can build a workflow for other high-impact conditions for your population — each one goes through the same sign-off gate before it ever runs.
Available on request
- Chronic kidney disease
- Depression
- Dementia
- Stroke recovery
- Post-discharge follow-up
Tell us the conditions that drive your admissions and we'll scope a workflow for them.
The same approach behind every condition.
Whatever the condition, a call does the same three things: listens for what tends to go wrong first, sorts it by urgency, and keeps a record over time.
It listens for the day-to-day signs
Each condition has the symptoms that tend to show up first when things are heading the wrong way. The call pays attention to those, in plain conversation — not a clinical questionnaire.
It sorts what it heard
Anything urgent pages a clinician now. Anything worth a second look goes to the review queue. The routine is logged and trended, so a slow drift shows up over weeks.
It works across more than one
Many patients carry several conditions at once. The check-in covers the ones that matter for that person on a given call, rather than treating each in isolation.
Triage is the same everywhere: urgent pages a clinician now, worth a look goes to the review queue, and routine is logged and trended. It extends the reach of your care team — it never replaces a clinician, diagnoses, or prescribes.
Built from guidance. Run only once your physician signs off.
Every workflow on this page starts as a draft built from published clinical guidelines — a structured starting point, not a finished standard of care. No workflow runs with real patients until a supervising physician signs it off — enforced in the database.
- Drafted from published guidanceA structured starting point for review — never content any physician has approved yet.
- Your physician owns the lineA supervising physician on your side edits each workflow and decides what counts as a concern.
- Enforced, not promisedUntil that sign-off exists, the workflow can't be assigned to a real patient. The block lives in the database.
See it run on your conditions. In twenty minutes.
Tell us the conditions that drive your admissions and we'll walk a real check-in call on your patient mix — the calls, the escalation path, and the CCM documentation your team would bill. The real product, not slides.
A real person replies — usually the same business day. No sales sequence, no obligation.