Healthcare · Care Coordination

Chronic Condition Care Plan Check-in

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

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

  1. Agent runs the check-in per the care plan's cadence, pulling the structured questions the care team set.
  2. Pulls in connected remote monitoring data — glucose, blood pressure — if the patient uses a device.
  3. Escalates any response or reading outside the pre-set threshold immediately to the care team.
  4. 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%