Chronic care follow-up for organizations accountable for outcomes and cost.
When your organization carries the outcomes and the total cost of care, what happens between visits matters as much as the visit itself. Every chronic patient gets a weekly check-in, and your physicians get one view of how each patient is doing.
What changes between visits
- Every patient is contacted every week, not only the ones a care manager has time to call.
- Missed doses, side effects and overdue labs are visible before the next visit, not at it.
- Physicians read one summary per patient instead of chasing calls and messages.
How it supports the measures in your contracts
| Measure you are accountable for | What the weekly check-in adds |
|---|---|
| Medication adherence | Doses reported every week, with the reason when one is missed |
| Diabetes and blood pressure control | Reminders for overdue HbA1c and other labs, with your booking link |
| Care plan completion | Goals set by your physicians, followed week by week |
| Avoidable utilization | Side effects and lapses visible in the week they happen |
| Care team capacity | Routine check-ins handled automatically, so staff focus on patients who need them |
We agree on the measures with each partner before launch and report them. We do not claim outcome results we have not measured yet.
Who it is for
- Accountable Care Organizations, including MSSP and ACO REACH participants
- Medical groups and primary care organizations with value-based or risk-bearing contracts
- Chronic care programs, starting with type 2 diabetes and obesity, including GLP-1 therapy
One loop, every week, for every patient.
- 01
Patients check in
An automated text in your clinic’s name opens a two-minute check-in. One tap per question.
Your weekly check-in is ready. It takes 2 minutes. Open my check-inAny nausea this week?NoneMildModerateSevere - 02
Answers become structured data
Each answer is stored as patient-reported information, week after week, in one longitudinal record.
- Dose this weekTaken
- Home weight196.4 lb
- NauseaMild
- Protein goal5 of 7 days
- 03
Physicians see the whole panel
One dashboard shows who is on track and who missed doses or reported side effects, before the next visit.
- Sarah MitchellOn track
- Marcus ReedNeeds review
- Linda ParkNeeds review
- Priya RamanAwaiting reply
Protocols written by physicians and approved by your medical director.
What your physicians see.
Pick a patient. Demo data, all patients are fictional.
This week, on Marcus’s phone.
Questions
No. Routine weekly check-ins run automatically, so care managers spend their time on the patients who need a person.
No. Patients are enrolled from a list your team provides and take part through a text message and a secure link. Protocols are approved by your medical director before launch.
Before launch we agree on measures such as check-in response rate, adherence and care plan completion, compare them over time and report them to you.
See your patients’ weeks, not just their visits.
A 30-minute walkthrough of the patient check-in and the physician dashboard, with demo patients.
We reply within one business day.