For health systems
Expand your panel without expanding headcount, and start closing your readmission-penalty exposure this quarter.
Your panel: the patients your clinicians are responsible for. Readmission penalties: Medicare pays hospitals less when too many patients bounce back within 30 days; about 78% of hospitals are penalized.3
Programs
pre-built across the cardio-kidney-metabolic track and oncology
Every Program above was written by the specialists who treat the condition, versioned and immutable, and every call it makes can be replayed.
Complete packages, ready to run.
Each Program ships whole: the calling schedule, the questions, the adherence logic, and the persistence to actually reach people. Carrie texts before she calls, leaves a voicemail that says when she'll try again, retries at hours that work, and calls back when asked. The cadence tightens when risk rises and loosens as patients stabilize. And between every scheduled call, patients can call her, any hour, with any question; she answers, and routes to the care team when they're needed.
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Heart failure
The cadence
Daily calls the first week home, when readmission risk peaks; tapers as the patient stabilizes; any warning sign pulls it back to daily.
On every call
Breathing at rest, lying flat, and on stairs; swelling in legs or belly; sudden weight gain (2 to 3 pounds overnight is fluid, and fluid is the signal); dizziness.
Keeps on track
The diuretic (water pill) and the rest of the med list, refills actually picked up, salt and fluid limits, the daily weigh-in.
Texts before calling · voicemail + callback · cadence tuned to risk · 24/7 inbound line · clinician-verified escalation
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Hypertension
The cadence
Weekly while finding the right dose, monthly once controlled; a run of high readings tightens it.
On every call
Home cuff readings and their trend, dizziness or lightheadedness (often a dosing signal), headaches or vision changes.
Keeps on track
Blood-pressure meds and refills, the home-cuff habit and technique, salt.
Texts before calling · voicemail + callback · cadence tuned to risk · 24/7 inbound line · clinician-verified escalation
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Diabetes
The cadence
Set by how controlled the patient is; new insulin starts get close, frequent attention.
On every call
Glucose patterns, low-sugar episodes (shaky, sweaty, confused), foot sores that won't heal, vision changes.
Keeps on track
Insulin and oral meds, refills, A1c lab draws on schedule, eating patterns that move the numbers.
Texts before calling · voicemail + callback · cadence tuned to risk · 24/7 inbound line · clinician-verified escalation
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Chronic kidney disease
The cadence
Monthly through stable stretches, tightening around lab draws and after any decline.
On every call
Swelling, changes in urination, blood-pressure readings, and new medications that stress the kidneys (common painkillers like ibuprofen top the list).
Keeps on track
Blood-pressure meds, the kidney diet (potassium and phosphorus limits), labs on schedule.
Texts before calling · voicemail + callback · cadence tuned to risk · 24/7 inbound line · clinician-verified escalation
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COPD (chronic lung disease)
The cadence
Steady through stable months, daily through and after a flare.
On every call
Breathlessness against the patient's own baseline, rescue-inhaler use (reaching for it more often is the early warning), cough and sputum changes.
Keeps on track
Daily inhalers and technique, refills, oxygen where prescribed, quit-smoking support when the patient wants it.
Texts before calling · voicemail + callback · cadence tuned to risk · 24/7 inbound line · clinician-verified escalation
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Oncology · chemotherapy
The cadence
Timed to the infusion cycle, calling on the days side effects usually peak, through the whole course of treatment.
On every call
Fever (after chemo a fever can be an emergency, and she treats it like one), nausea and whether anything stays down, mouth sores, numbness or tingling in hands and feet.
Keeps on track
Anti-nausea meds taken on schedule (they work best taken early), hydration, readiness for the next infusion.
Texts before calling · voicemail + callback · cadence tuned to risk · 24/7 inbound line · clinician-verified escalation
Multimorbid patients are the norm, so several Programs run at once for the same patient, and each shares what it learns with the others.
Carrie never diagnoses, prescribes, or places orders; clinical judgment stays with the care team.
The heart-failure math, modeled.
A modeled 5,000-patient cohort: published transition-of-care programs reduce readmissions in the 20 to 40% range.7 In scoping, we rebuild it with your numbers.
The patients portals never reach.
Carrie reaches the 40%+ of patients portals never do2: by phone, in their language, no app and no login.
One patient group, live in 90 days. Bring a workflow owner, an IT ticket, and a definition of which patients.