# Chronic Condition Care Plan Check-in — Healthcare AI agent | Mihu AI

Healthcare · Care Coordination

# Chronic Condition Care Plan Check-in

Run scheduled check-ins for patients on a chronic care management plan between visits.

Set up this outcome

## Apps this needs

EHR / Practice System Read availability and write appointments back to your clinic system. Connect during setup

SIP Trunk Route inbound & outbound calls through your phone system. Connect during setup

Remote Patient Monitoring Connected device data — glucose, blood pressure, vitals — between visits. Connect during setup

## How it works

Agent runs the check-in per the care plan's cadence, pulling the structured questions the care team set.

Pulls in connected remote monitoring data — glucose, blood pressure — if the patient uses a device.

Escalates any response or reading outside the pre-set threshold immediately to the care team.

Logs all responses to the care plan record for the next visit.

## Data sources

EHR care plan/protocol Remote patient monitoring device feed

## What it targets

Scheduled check-ins completed on cadence Target 85%

Out-of-threshold readings escalated within 1 hour Target 100%