Program · runs under care management leadership
High-risk & complex populationsContinuity for the patients who need it most — not the patients left over.
The patients who need the most continuity and, in practice, get whatever capacity is left over once the day's urgent work is done.
The population
Who the program is built around.
Risk stratification over the unified record surfaces them; your care team confirms the roster. These are rarely single-condition patients — the program follows everything they carry, rotating rather than repeating.
Several conditions at once
Heart failure and kidney disease and diabetes — one patient, one thread
A recent admission, or more than one
The pattern that predicts the next one
Complex regimens
Many prescribers, many pharmacies, and a list only the record keeps straight
Frail, or living alone
No one at home to notice the change between visits
Behavioral health alongside
The condition that makes every other condition harder to manage
Needs beyond the clinical
Transportation, housing, food — captured as structured needs and routed
The cadence — the most frequent of any program — is set by the risk each patient carries. Your team confirms who is enrolled and where escalations land, and can see at any point who on the roster was reached this week and who was not.
The contact
What each contact follows.
The most frequent contact of any program, set by the risk the patient carries rather than by the capacity the panel has.
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 · picking up Thursday's thread
“We spoke Thursday and you mentioned the swelling in your ankles. Has that settled down, stayed about the same, or got worse?”
Followed on every contact
- Contact at the frequency the risk warrants, not the frequency staffing allows
- Every condition the patient carries, rotating rather than repeating
- Change measured against this patient's own baseline
The split
The routine part completes on the contact. The rest reaches the care team.
Completed without a clinician
- The routine work that would otherwise consume the panel's attention
- Keeping continuity when a nurse is out, at capacity, or on something urgent
Text message · between calls
Sent to the care team
- Meaningful change in any of the patient's conditions
- A pattern across contacts that no single call would show
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.
Across contacts
A pattern no single call would show.
What reaches the care team from this program is often not one alarming sentence. It is a change across contacts, measured against the patient's own baseline — and the whole thread travels with the escalation.
Patient · contact thread
One week, one patient
- Weekly check-inThursday
Mentioned new swelling in her ankles. Mild, breathing unchanged. Held to follow on the next contact.
- Follow-up contactSunday
Swelling about the same. Weight steady against her own baseline. Kept in view.
- Weekly check-inWednesdayUrgent
Swelling worse and weight up since Sunday. Met the escalation criteria set in her program — sent to her care team with the whole thread attached.
Running the program
- What it writes back
- A continuous record for the patients where continuity matters most, rather than a gap between visits.
- Who owns it on your side
- Care management leadership. It sits with leadership because it changes how the panel's scarce clinical attention is allocated.
- 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. Agreed before the pilot starts — the only honest form of proof we offer.
Name the fifty patients you worry about.
Every care team can. The pilot is those patients, contacted on the schedule their risk calls for, every week — including the short-staffed ones.
Talk to our team