Improve Outcomes Across Entire Populations

• HbA1c monitoring and trend analysis
• Medication adherence tracking
• Retinopathy and nephropathy screening alerts
• Diet and exercise plan integration

• Blood pressure and cholesterol tracking
• Cardiac event risk prediction
• Medication titration recommendations
• Cardiac rehab program enrollment

• Spirometry result tracking
• Exacerbation prediction
• Inhaler technique education
• Pulmonary rehab coordination

• eGFR monitoring and staging
• Dialysis readiness planning
• Medication dosing adjustments
• Transplant evaluation coordination

High-Risk Patient Identification

1. 1
   AI analyzes claims, EHR, and social determinants data
2. 2
   Risk scores calculated and updated daily
3. 3
   High-risk patients flagged for care management
4. 4
   Care managers receive prioritized work queue

Care Plan Creation & Execution

1. 1
   Evidence-based care plan templates by condition
2. 2
   Personalized interventions based on patient factors
3. 3
   Automated task assignment to care team members
4. 4
   Progress tracking and care plan adjustments

Patient Engagement

1. 1
   Automated outreach via phone, email, SMS, or portal
2. 2
   Educational content tailored to patient conditions
3. 3
   Appointment and medication reminders
4. 4
   Health coaching and motivational interviewing

Outcomes Monitoring

1. 1
   Real-time tracking of clinical metrics and utilization
2. 2
   Automated alerts for deteriorating patients
3. 3
   Quality measure performance dashboards
4. 4
   ROI analysis and program effectiveness reporting