Platform · Continuous follow-up
Follow-up that never starts over.
Between visits, LifeWatch checks in with every enrolled patient, handles the routine work on the contact, and brings the care team the exceptions — with each conversation shaped by what that patient's own story already says.
Most of the work finishes quietly. The exceptions rise with everything a clinician needs.
Continuous contact for everyone must not mean another inbox for the care team. So routine work completes on the contact and writes itself back, and what reaches a person arrives with the reason, the context, and what has already been done.
Handled on the contact
No clinician task createdChronic care
Monthly follow-up completed; adherence recorded per medication
Post-discharge
Cardiology appointment booked and confirmed by text
Medication management
Refill routed to the pharmacy queue that owns it
Care gaps
Screening explained; the prep objection answered; appointment booked
Annual wellness
Eligibility explained; patient declined; reason recorded
High-risk panel
Weekly check-in completed; no change against baseline
Care team review
Post-discharge · day 6
New breathlessness at night, and weight up since discharge
Why it surfaced
- Discharged with heart failure six days ago
- Weight up against her own discharge baseline
- Newly reported breathlessness when lying down
Already handled
- The measurement confirmed with the patient
- Diuretic adherence discussed and recorded
- Transcript written back, triggering sentence marked
Routed to Her own care manager, with the covering clinician copied
Raised because it met criteria written into the program. LifeWatch applies the rule; it does not decide what the rule should be.
The outcome — what the care team decided and did — is written back into the patient's profile. The next contact opens knowing it.
The routine care management your teams already own, done between visits.
Most of it completes on the contact without becoming anyone's task.
- Post-discharge follow-up
- Condition check-ins
- Medication adherence
- Refill routing
- Scheduling and confirmation
- Care-gap outreach
- Preventive care and wellness visits
- Education, when it is relevant
- Barrier discovery
- Patient-reported information
For clinical reviewers: each kind of work, how context shapes it, and the boundary
What a contact can carry.
Depending on the patient's condition, history, program and what they said last time, a contact can carry any of this — and most of it completes without becoming anyone's task.
Post-discharge follow-up
The days after going home: instructions understood, new medications started, symptoms against the discharge baseline, the follow-up visit that should exist.
Condition check-ins
Heart failure, diabetes, COPD, hypertension and the rest — what the program says to follow for that condition, measured against this patient's own baseline.
Medication adherence
Each medication on the patient's real list, and what is getting in the way: cost, timing, side effects, a refill that never arrived.
Refill routing
A refill that ran out is routed to the queue that owns it on the same contact — not discovered at the next visit.
Scheduling and confirmation
Appointments offered, booked, confirmed and chased, including what has to happen first: the lab before the visit, the ride to get there.
Care-gap outreach
The open gap explained in the patient's own terms, the booking moved forward, and the real objection recorded when they decline.
Preventive care and wellness visits
Eligibility explained plainly, the visit described for what it is, and the booking landed in your scheduling workflow.
Education, when it is relevant
The program's teaching delivered on the contact where it matters, put in writing the same day, and checked on a later one.
Barrier discovery
Transport, cost, food, housing, the thing nobody wanted to admit at the visit — captured as structured needs and routed to whoever handles them.
Patient-reported information
Weight, readings, symptoms, mood, and circumstances recorded against the record — for the next contact and for the care team.
Teaching is an action inside the program, and it is checked.
Education is not a separate campaign. It is content inside each condition program, delivered on the contact where it becomes relevant, put in writing the same day, and confirmed on a later contact — so nothing is re-taught out of doubt or dropped out of optimism.
Education · topic record
Topic followed across contacts
- Topic
- What to do when the number on the scale jumps
- Taught
- On a check-in, after a weight question
- In writing
- Short summary sent by text the same day
- Checked
- On the following contact
- Result
- Described it back correctly
- Next
- Topic closed — will not be re-taught
The same check-in is a different conversation for every patient.
The program defines what a contact may cover and what must escalate. What the patient's story says decides how the conversation actually goes — what it opens with, what it watches, and how closely it follows up.
- 01
Discharged six days ago with a new diuretic
- Opens with
- With the weight, the breathing, and whether the new pill was started — because the discharge summary says those are the things that matter this week.
- Watches for
- Any change against the weight recorded at discharge.
- 02
Stable for months, missed the evening dose twice last month
- Opens with
- With the evening dose, because that is what she said was hard — not with a general question about medications.
- Watches for
- Whether the change she agreed to actually held.
- 03
Declined a screening twice; the prep was the objection
- Opens with
- With the objection, not the reminder. The program's answer to that objection, then the booking.
- Watches for
- A reason for declining, recorded, rather than a third unanswered attempt.
All of that comes from the patient profile, which every contact reads before it starts and writes to when it ends.
Voice and text are how it reaches people. They are not what it is.
Older patients answer a phone; others will only ever text. The program, the boundary, and the memory are the same in both, so a conversation can start by voice on Tuesday and continue by text on Thursday without anyone being asked to repeat themselves.
Hands over mid-conversation
When something meets the program's escalation criteria the agent stops, tells the patient a nurse will call, and routes it — rather than finishing the script first.
Follows a tangent and comes back
Patients do not answer in order. The agent can be interrupted, go where the patient goes, and still return to what the contact came to cover.
Speaks the patient's own numbers
Their weight, their last result, what they said last time — the contact starts from their record, not from a generic script about their condition.
Draws out the real reason
Guiding rather than instructing, because telling people what to do is the approach that has already not worked for them. Cost, side effects, transport, and the thing they did not want to admit.
Recognizes who is actually speaking
A daughter answering her father's phone is a normal event, not an error. The agent handles a caregiver on the line, and records who it spoke to.
Remembers what was agreed
What the patient committed to on the last contact is what this one opens with. Nobody is asked the same question twice because two systems were not talking.
Books, confirms, and chases
Including what has to happen first: the lab before the visit, the authorization before the procedure. An appointment offered is one that can actually take place.
Asks about the rest of it
Housing, food, getting to the clinic, affording the prescription. Captured as structured needs, coded, and routed to whoever in your organization handles them.
Works in the patient's language
The same clinical content and the same boundaries, spoken the way the patient actually speaks. And by text, for the patients who will never pick up a phone.
The conversation adapts. The boundary does not.
Everything above happens inside a program a clinician wrote and certified: what a contact may cover, what it may resolve on its own, and what must reach a person. The AI chooses the next question from what the patient says. It never chooses the boundary.
What every contact writes back
Structured note
Written to the patient's chart in your system of record
Full transcript
Stored and linked, with the triggering sentence marked
Actions taken
Appointments, referrals, refill routing, education delivered
Findings
Symptoms, adherence, and circumstances recorded against the record
Program position
Which contact this was, and when the next one is due
Time and activity
Captured in the form your billing team already works from
One system, four views
The platform overviewPick one population and one program.
We map the follow-up against how your team works today, agree what a pilot measures before it starts, and show your clinicians exactly what would reach them.
Talk to our team