Chronic Disease Outreach Agent
Orchestrates outreach for diabetes, CHF, COPD, and hypertension cohorts based on control metrics.
Disease management programs rely on static registries and manual chart review to find patients out of control, so outreach is delayed, uneven across clinics, and poorly matched to severity
Care teams lack a unified view of A1c, BP, EF, exacerbations, and refill gaps, leading to missed quality opportunities and preventable acute events
The Chronic Disease Outreach Agent continuously monitors cohort control metrics for diabetes, CHF, COPD, and hypertension, prioritizes members by clinical urgency, and orchestrates multi-channel outreach with care pathways tailored to each condition
The agent maintains condition-specific cohorts, evaluates latest labs, vitals, meds, and utilization against control thresholds, and launches sequenced outreach campaigns. It books or proposes appointments, routes complex cases to nurses or pharmacists, and closes the loop when metrics improve or patients decline engagement.
Build and Refresh Disease Cohorts
- Identify active diabetes, CHF, COPD, and hypertension members from diagnoses, meds, and registry rules
- Attach latest A1c, BP, eGFR, BNP/NT-proBNP, spirometry, and exacerbation events
- Remove deceased, disenrolled, or hospice patients and tag preferred contact channels
Score Control Gaps and Urgency
- Flag out-of-control thresholds (e.g., A1c >9, SBP ≥160, recent COPD exacerbation, CHF weight gain alerts)
- Rank outreach priority by acuity, days since last contact, and quality measure impact
- Select pathway templates: nurse titration, pharmacy med review, PCP visit, or remote monitoring enrollment
Orchestrate Multi-Channel Outreach
- Send SMS, portal, IVR, or care-manager call sequences based on preference and urgency
- Offer self-scheduling links or warm-transfer to scheduling for overdue visits and labs
- Document attempts, responses, and barriers (language, transport, cost) in the care plan
Track Outcomes and Re-Engage
- Monitor post-outreach labs, vitals, and fill adherence for control improvement
- Escalate non-responders and high-acuity declines to care management
- Report cohort control rates and campaign ROI to population health leadership