Reach the whole attributed panel, between visits.
Shared savings turn on the admissions you prevent — and most of those start at home, weeks before anyone calls. Family Guardian AI checks in with your highest-risk attributed patients between appointments, surfaces the few who are slipping, and gets the urgent ones to a clinician in real time.
- HIPAA-compliant
- BAA-ready
- CPT 99490-native
- Transparent AI
Your panel, ranked by risk
The few who need attention today, surfaced from the whole panel.
Short of breath on the stairs this week and up a few pounds since the last check-in. Routed to the care team now.
Mentioned she ran out of one medication and hasn't refilled. In the review queue for today.
Breathing easier than last week and picked up her refill on time. Logged and trended.
Avoidable admissions don't start in the hospital.
They start at home — a missed dose, a symptom that creeps up, a refill that never happened. By the time a high-risk patient is back in front of your care team, the cheap window to intervene has usually closed. The whole attributed panel is exposed to this, and no care team has the hours to call everyone.
- Most of your spend concentrates in a small, high-risk slice of the attributed panel.
- A large share of admissions are for conditions that respond to early, simple outreach.
- The patients who decline quietly are exactly the ones who don't call in.
- Care teams know early contact matters — they just can't reach everyone in time.
Every one of these is a chance to reach the patient first — before it becomes the expensive version of itself.
Panel-wide reach, without panel-wide staffing.
One layer that calls everyone on your behalf and hands your care team only the patients who actually need them.
Reach the whole panel
Regular check-in calls across your entire high-risk attributed population — not just the patients who happen to come in. The reach scales without adding headcount.
Catch decline earlier
The AI listens for the early signs that lead to hospital stays and flags them while there's still a cheap way to act — so concerns surface in days, not at the next visit.
Protect shared savings
Fewer avoidable admissions is the lever that moves your number. Reaching high-risk patients earlier, more often, is the most direct way to pull it.
Document CCM along the way
Each qualifying call is structured into the CCM documentation your team bills under CPT 99490 — a supporting revenue line, generated as a by-product of the outreach you're already doing.
From attribution list to a ranked queue.
You give us the panel and the standard. We do the calling and hand back only what needs a human.
- 01
We call your high-risk patients
On a cadence you set, the AI places calm, natural check-in calls across your attributed panel — on each patient's own schedule, in plain conversation.
- 02
We triage what we hear
Every call is sorted into three buckets: urgent pages a clinician now, worth-a-look lands in a ranked review queue, routine is logged and trended in the console.
- 03
Your team acts on the few
Your care managers open the day to a short, prioritized list instead of a panel they could never finish — with the context to act on each one.
You bill. We document. Each qualifying check-in across your attributed panel is structured into the documentation Medicare asks for under CPT 99490, so the outreach that protects your savings also supports a CCM revenue line. We generate the documentation, not the reimbursement — and whether a call qualifies depends on your practice meeting CMS requirements.
It extends your care team — it never replaces it.
No workflow runs with real patients until a supervising physician signs it off — enforced in the database.
Every clinical workflow the AI follows is content your supervising physician controls. None of it reaches a real patient until they sign it off. The AI does the reaching out and the listening; your clinicians make every clinical decision — it never diagnoses or prescribes.
- Nothing runs unsignedA workflow can't be assigned to a real patient until a supervising physician signs it off — enforced in the database, not just in policy.
- Your physician, your standardThe supervising clinician is on your side. You decide what the AI covers and where the line sits.
- Urgent reaches a human, fastUrgent signs page a clinician right away; the worth-a-look ones land in a review queue; routine calls are logged and trended.
See it run on your panel. In twenty minutes.
A working walkthrough on your patient mix and your geography — the real product, not slides. We'll show the calls, the escalation path, and the CCM documentation your team would bill.
A real person replies — usually the same business day. No sales sequence, no obligation.