Proactive outreach that keeps patients engaged in their care journey
AI-driven follow-up campaigns for chronic care management, medication adherence, post-discharge check-ins, and wellness programs — reaching patients at the right time through the right channel.
Built for Care Management, Population Health & Patient Engagement Leaders
The Problem
Why manual triage doesn't scale
Patient Drop-Off from Care Programs
Patients enrolled in chronic care, wellness, or post-surgical programs disengage quickly without consistent follow-up and encouragement.
50% of patients drop out of chronic care programs within 6 months
Medication Non-Adherence
Patients forget to take medications, skip refills, or stop treatment early — leading to avoidable complications, readmissions, and worse outcomes.
Non-adherence causes 125,000 preventable deaths annually in the US
Post-Discharge Follow-Up Gaps
Care teams struggle to reach every patient within the critical 48-72 hour post-discharge window, increasing readmission risk.
Care Coordinators Are Stretched Thin
Manual outreach by phone is time-consuming and unscalable. Care coordinators can only reach a fraction of their patient panels each day.
Average care coordinator manages 80-120 patients
Results
Measurable impact from day one
45%
Higher Program Retention
Consistent, personalized follow-up keeps patients engaged in care programs longer.
35%
Better Medication Adherence
Automated reminders and check-ins improve refill rates and treatment compliance.
50%
Fewer Readmissions
Proactive post-discharge outreach catches warning signs before they become emergencies.
4x
Outreach Capacity
AI extends care coordinator reach to contact every patient, not just the highest-risk.
Capabilities
Everything you need for intelligent triage
Chronic Care Outreach Engine
Automated, personalized check-ins for patients in chronic care programs — diabetes management, cardiac rehab, behavioral health, and more.
- Condition-specific conversation templates
- Symptom and vitals collection via chat or SMS
- Escalation to clinical staff for concerning responses
Medication Adherence Campaigns
AI-powered reminders for medication schedules, refill prompts, and side-effect check-ins that adapt to patient behavior.
- Personalized dosing schedule reminders
- Pharmacy refill coordination and reminders
- Side-effect monitoring with clinical escalation
Post-Discharge Monitoring
Automated outreach within 48 hours of discharge to assess recovery, reinforce care instructions, and schedule follow-ups.
- Automated post-discharge wellness checks
- Recovery assessment questionnaires
- Follow-up appointment scheduling prompts
Population Health Dashboard
Track program enrollment, engagement rates, adherence metrics, and health outcomes across your patient population.
- Program enrollment and retention analytics
- Risk stratification and intervention tracking
- Outcome reporting for value-based care contracts
How It Works
Three steps to automated triage
Step 1
Enroll & Segment
Patients are enrolled in care programs and segmented by condition, risk level, and communication preference for personalized outreach.
Step 2
Engage & Monitor
AI delivers scheduled check-ins, medication reminders, and wellness assessments via the patient's preferred channel.
Step 3
Escalate & Report
Concerning responses trigger clinical escalation. Population-level analytics drive program optimization and outcomes reporting.
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Frequently asked questions
What kinds of care programs does this support?
Chronic care management, medication adherence, post-discharge monitoring, and wellness programs. Patients are enrolled and segmented by risk and program stage, then contacted on the channel and cadence appropriate to that segment, rather than on a single broadcast schedule that treats every enrolled patient identically.
How does proactive outreach reduce readmissions?
Post-discharge check-ins catch deterioration, medication confusion, and missed follow-up appointments while they are still cheap to fix, which is usually the first week after discharge. Structured responses escalate to a care coordinator, and organisations running this typically see readmissions fall by around half.
Can care coordinators still intervene directly?
That is the design. The workflow handles routine outreach and monitoring, roughly quadrupling outreach capacity, and escalates the patients whose responses warrant a human conversation. Coordinators spend their time on genuine exceptions rather than working sequentially through a call list of stable patients.
Related Glossary Terms
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