CLINICAL PERFORMANCE AGENTS
Clinical Performance Agents handle the outreach your coordinators cannot keep up with — so every patient gets reached, not just the top of the list.
A Director of Care Management running a 15,000-life MSSP ACO might have eight coordinators. On any given day, their combined capacity might cover 40 to 60 meaningful patient interactions. The list of patients who need attention is three or four times that. Clinical Performance Agents handle the execution work that coordinators run out of bandwidth for — not as a replacement for the care team, but as the operational layer that ensures no patient falls off the list.
Handles the ongoing, recurring outreach work for patients with active chronic conditions. Medication adherence check-ins, symptom escalation, CCM and PCM billing workflow support, risk-tiered outreach, care plan reinforcement, and specialty care coordination.
Post-discharge follow-up, medication reconciliation, and care transition management. Every discharged patient is contacted within the TCM window, barriers are captured, follow-up appointments are scheduled, and clinical escalations are routed.
AWV outreach, quality gap reminders, vaccination campaigns, and preventive screening follow-up. Two-way engagement that captures barriers, routes resolution, and tracks whether the gap actually closed before the performance-year deadline.
Structured social determinants screening integrated into outreach interactions. Captures housing, food, transportation, and financial barriers and routes to the appropriate community resource or internal care coordinator.
Find out how Clinical Performance Agents can help your organization reach every patient on the care management list — not just the ones your team has bandwidth for.
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