Programs
Programs for the work your teams already own.
Nothing here is a feature. These are operations a health system already staffs and reports on, each running on the same follow-up layer — grouped by the problem they answer, with the owner, the escalation boundary, and the pilot measure in plain view.
Around a hospital stay
The highest-stakes window in the calendar: contact is thinnest exactly when the risk of coming back is highest.
One program
- 01Transitions of care
Post-discharge
The days after a discharge decide whether a patient comes back, and that is exactly when contact is thinnest.
The program in detailReaches the care team
- Symptoms suggesting the original problem is returning
- A medication the patient never started, or stopped
- Anything the patient describes that the call is not scoped to answer
What a pilot measures
Share of discharged patients reached inside the window, and the share whose follow-up appointment was booked before it lapsed.
Ongoing, between visits
The standing work of a care-management operation — condition follow-up, medications, and the patients who need more contact than any panel can staff.
3 programs
- 02Care management
Chronic care & APCM
Patients with ongoing conditions need contact between visits at a frequency no team can staff by hand.
The program in detailReaches the care team
- A condition-specific finding the program defines as urgent
- Anything the patient raises that falls outside what the call is scoped to handle
What a pilot measures
Share of the enrolled panel actually reached each month, and the volume of routine work resolved without a clinician touching it.
- 03Pharmacy / care management
Medication management
Adherence is asked about at visits and assumed in between, where the actual failures happen.
The program in detailReaches the care team
- A side effect the patient is describing
- A medication stopped without anyone knowing
- Any request to change a dose — LifeWatch never does this
What a pilot measures
Adherence problems identified per patient contacted, and the share resolved on the contact rather than referred onward.
- 04Care management leadership
High-risk & complex populations
The patients who need the most continuity get whatever capacity is left over.
The program in detailReaches the care team
- Meaningful change in any of the patient's conditions
- A pattern across contacts that no single call would show
What a pilot measures
Continuity: the share of high-risk patients contacted on schedule every period, including the weeks when the team is short-staffed.
Preventive care and quality lists
The lists your quality and operations teams already report on, worked to real outcomes instead of attempt counts.
2 programs
- 05Quality / population health
Care gaps & preventive care
Open gaps are known months before they are worked, because working them is manual phone labor.
The program in detailReaches the care team
- A symptom that surfaces during the outreach and is unrelated to the gap
- A patient whose circumstances mean the gap should not be worked as written
What a pilot measures
Gaps closed per hundred worked, and the share of attempts that produced a real outcome rather than an unanswered call.
- 06Primary care operations
Annual wellness visits
AWVs are the most reliably reimbursable preventive contact and the most consistently under-booked.
The program in detailReaches the care team
- A concern raised during the outreach that should not wait for the visit
What a pilot measures
Share of eligible patients who booked, and the share of declines with a reason recorded rather than an attempt logged.
One follow-up layer. The programs are what your teams call the work.
A program decides what a contact covers, how often, and what must escalate. Everything else — the patient's story, the conversation, the boundary, the write-back — is the same platform running underneath.
The same profile
A patient in three programs has one thread, not three call schedules. Every contact reads the same story and writes to it.
The same conversation
Interrupted and answered, in the patient's language, by voice or text, drawing out the real reason — the capabilities are shared, the content is the program's.
The same boundary
What a contact may cover, may resolve on its own, and must escalate is written into each program by our clinicians and reviewed by your team before go-live.
Bring us the one that is costing you the most.
We will tell you plainly whether continuous follow-up changes it, and what a pilot on that program would actually involve.
Talk to our team