Automated Care Coordination & Follow-Up
Streamline post-visit follow-ups and chronic disease management with an intelligent virtual care assistant. Engage patients, monitor their health, and alert your care team only when intervention is needed – all while keeping data seamlessly synced with your EHR.
- Automated Patient Check-Ins
- Medication & Appointment Reminders
- Real-Time Alerts for Clinicians
- EHR Integration via FHIR
Challenges in Post-Visit Care and Chronic Disease Management
Providers often struggle with coordinating post-visit care and chronic disease management. After a patient leaves the clinic or hospital, ensuring they follow care plans (attending follow-ups, taking meds, monitoring vitals) usually requires time-consuming outreach by care managers or nurses.
Many patients don’t respond, resulting in missed appointments, unmanaged symptoms, and avoidable readmissions. This is a significant issue in U.S. healthcare delivery – poor care coordination contributes to higher emergency visits and complications.
Many patients don’t respond, resulting in missed appointments, unmanaged symptoms, and avoidable readmissions. This is a significant issue in U.S. healthcare delivery – poor care coordination contributes to higher emergency visits and complications.
Difficulty Coordinating Follow-Ups
- Manual outreach by care managers and nurses is time-consuming
- Patients often miss scheduled appointments
- Providers lack real-time visibility into patient recovery
Medication Adherence Issues
- Patients forget to take medications on time
- Confusion over dosage or instructions leads to errors
- Lack of reminders increases the risk of complications
Monitoring and Symptom Tracking Gaps
- Patients may not track vital signs or symptoms at home
- Abnormal readings often go unnoticed until the next visit
- Delayed detection can lead to preventable health crises
Impact on Healthcare Outcomes
- Increased emergency visits due to unmanaged conditions
- Higher rates of avoidable hospital readmissions
- Strain on care teams and overall healthcare resources
Direct Patient Engagement with Seamless EHR Integration
Patient-facing – the agent interacts directly with patients on behalf of the care team.
Patient-Facing Virtual Care
The AI agent serves as a virtual care coordinator, interacting directly with patients on behalf of the care team. It conducts routine follow-ups, checks on recovery, reminds patients about medications and appointments, and answers common questions. By engaging patients proactively, it improves adherence to care plans, reduces missed visits, and empowers patients to take a more active role in managing their health—all without adding extra workload to nurses or care managers.
Seamless FHIR EHR Integration
All patient interactions, responses, and health measurements are securely logged in the electronic health record using FHIR standards. Observations, care plans, and goal progress are automatically updated, and clinicians are notified in real time if any critical issues arise. This ensures a complete, accurate, and actionable view of each patient’s health, enabling timely interventions and better coordinated care across the care team.
AI-Powered Virtual Care Coordination
An AI agent can act as a virtual care coordinator, handling routine follow-ups and check-ins. For example, after a hospital discharge, an AI chatbot could message the patient (via SMS or patient portal) or an AI voice Bot could call them at home. It would ask standardized questions about their recovery (“How are you feeling? Any fever or pain?”), remind them about medications and upcoming appointments, and answer common questions. For chronic disease patients, the agent might schedule periodic wellness check-ins to log symptoms or home measurements (like asking a diabetic patient for their latest glucose readings).
All patient inputs are processed with NLP to determine if there’s a concern – the agent can trigger an alert for a human nurse to intervene if needed (e.g. patient reports worsening symptoms or an out-of-range reading). This ensures timely intervention while reducing the need for staff to manually call every patient.
All patient inputs are processed with NLP to determine if there’s a concern – the agent can trigger an alert for a human nurse to intervene if needed (e.g. patient reports worsening symptoms or an out-of-range reading). This ensures timely intervention while reducing the need for staff to manually call every patient.
Real-Time EHR Integration with FHIR
The agent can write the collected data back into the EHR using FHIR resources (e.g. recording a blood pressure reading as an Observation, or updating a Care Plan or Goal completion status).
It can also utilize FHIR Subscription or Task services to notify the provider in real time if critical issues are detected. Integration with EHR via FHIR ensures the virtual agent’s activities are part of the patient’s record and visible to the care team.
It can also utilize FHIR Subscription or Task services to notify the provider in real time if critical issues are detected. Integration with EHR via FHIR ensures the virtual agent’s activities are part of the patient’s record and visible to the care team.
Transform Patient Care with AI-Driven Coordination
Keep patients engaged, improve adherence, and prevent readmissions with an AI care coordinator that automates follow-ups and integrates seamlessly with your EHR.
