CHRONIC & LONGITUDINAL CARE MANAGEMENT
The Chronic & Longitudinal Care Management Agent runs monthly touchpoints, medication adherence check-ins, and symptom escalation for every enrolled patient — regardless of how many are on the list.
In a 10,000-life MSSP ACO, a care management team might have 800 to 1,200 patients actively enrolled in a chronic care management program — each needing a documented monthly touchpoint for CCM billing, medication adherence monitoring, and care plan follow-through. A coordinator managing 150 patients cannot sustain that contact volume consistently. Care management platforms have improved visibility, but they do not reduce the work they make visible.
Continuous watch on medication fills, symptom patterns, lab trends, and ADT events across the enrolled population. When concurrent signals cross a configured threshold, a structured alert fires to the appropriate care team member with full context.
Two-way outreach that does not just remind patients to take their medications — it asks whether they are, and captures the actual barrier when they are not. A patient rationing insulin because of cost routes to a patient assistance coordinator.
When a patient reports a worsening symptom during any outreach interaction, the agent captures clinical detail and escalates to the appropriate care team member based on protocol. Urgency, symptom type, and patient risk tier inform routing.
Every documented patient interaction contributes to the monthly time threshold required for CCM and PCM billing. The agent generates billing-compliant records that track interaction duration, clinical content, and care plan relevance.
Find out how the Chronic & Longitudinal Care Management Agent can help your organization sustain consistent monthly touchpoints for every enrolled chronic care patient.
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