Program · runs under care management
Chronic care & APCMFollow-up at the frequency the condition requires, not the frequency the panel allows.
Patients carrying one or more chronic conditions who need contact between visits at a frequency the panel cannot support by hand.
The conditions
A program per condition, not a script per call.
Each condition runs its own multi-month program — what to follow, what to teach, and what must escalate — built on established behavior-change practice and written at an eighth-grade reading level.
Heart failure
Weight, swelling, breathing — against this patient's own baseline
Type 2 diabetes
How the numbers are running, and what eating actually looks like
COPD
Breathing against baseline, inhaler technique, early signs of a flare
Hypertension
Home readings, and whether the medication is really being taken
Chronic kidney disease
The medications that need care, and the diet that is hard to hold
Coronary artery disease
Chest symptoms, activity tolerance, and keeping the regimen going
Atrial fibrillation
The anticoagulant, the missed doses, the questions that cannot wait
Depression & anxiety
Mood against baseline, and whether treatment is being kept up
You configure the deployment: who is enrolled, on what cadence, and where escalations land. A patient carrying three of these conditions gets one thread, rotating through what they carry — not three competing call schedules.
The contact
What each contact follows.
Regular contact between visits at the interval the program sets for the condition — typically monthly, more often when something has changed.
Every attempt ends as a recorded outcome — so who was actually reached this month is a fact your team can pull, not a guess.
Voice call · this month's check-in
“Last month you told me the evening dose was the one you kept forgetting. Has that got any easier since you started keeping them by the kettle?”
Followed on every contact
- How the condition itself is behaving, against this patient's own baseline
- Whether medications are being taken, and what is getting in the way
- Whether the next appointment exists
- What changed since the last contact
The split
The routine part completes on the contact. The rest reaches the care team.
Completed without a clinician
- Booking the follow-up that was never scheduled
- Routing a refill that ran out early
- Delivering the program's teaching when the patient is unclear
Text message · after the call
Sent to 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
An escalation arrives with the transcript, the triggering sentence, and the change against this patient’s own baseline — in the patient’s own care team’s queue, ranked by severity.
The escalation rules are written and certified by our clinicians before any patient is contacted. How programs are designed.
The record behind the rhythm
Every check-in reads this before it dials, and writes to it after.
Conditions, medications, labs, appointments, what matters to the patient personally, and every previous conversation — which is why month three continues month two instead of repeating month one.
Patient · longitudinal record and outreach history
Mary Henderson
72 years · DEV-001 · CHF · Type 2 diabetes · Hypertension
72-year-old with CHF, type 2 diabetes, and hypertension. Recent fasting glucose is above her individualized range. Weight and breathing remain stable. Last contacted 24 minutes ago.
Blood pressure
138/82mmHg
Within her usual range
Weight
164.2lb
Within her usual range
O₂ saturation
96%
Within her usual range
Fasting glucose
168mg/dL
Above her usual range
Medications
- Metformin 500 mgTwice daily
- Lisinopril 10 mgDaily
- Furosemide 20 mgDaily
- Atorvastatin 20 mgNightly
Labs
- A1c7.9%Aug 22, 2026
- eGFR62Aug 22, 2026
- Potassium4.3Aug 22, 2026
Appointments
- CardiologySep 4, 2026
- Primary careSep 18, 2026
Outreach history
- Diabetes check-inToday, 9:14 AM
Reviewed glucose readings and medications. Reinforced diet and hydration. Fasting glucose above her usual range.
- CHF weekly check-inAug 22
Breathing stable, no swelling. Weight unchanged. Taking medications as prescribed.
What matters to her
- Lives alone
- Daughter visits Tuesdays
- Prefers mornings before 10
- Uses a pill organizer
- Transportation available
Care team
- DOD. Okafor, RNCare Manager
- PWDr. P. WhitfieldPrimary Care
Running the program
- What it writes back
- A structured note from the contact that supports the chronic-care documentation your billing team already produces. Your practice bills; LifeWatch documents.LifeWatch documents the contact. Your practice performs and bills the service — we never bill on your behalf, and nothing here is billing advice.
- Who owns it on your side
- Care management. The team already accountable for keeping the panel followed between visits. The program adds the contact, not another queue to staff.
- 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. Agreed before the pilot starts — the only honest form of proof we offer.
Pick one condition and one panel.
Chronic care is where the arithmetic is starkest: the follow-up the condition calls for, times the panel, is a number no team can staff by hand. Start there.
Talk to our team