Chronic Disease Outreach Agent

The work it takes off your plate

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.

How it works

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.

1. Step 1: 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

   Result: Up-to-date chronic disease cohorts with current control metrics and contact preferences.

2. Step 2: 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

   Result: Prioritized outreach queues with recommended pathway for each member.

3. Step 3: 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

   Result: Campaign activity logged with appointments scheduled or barriers captured for follow-up.

4. Step 4: 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

   Result: Closed-loop disease management with measurable improvement in control metrics.

Why use it

• Condition-Specific Pathways. Tailored logic for diabetes, CHF, COPD, and hypertension.
• Control-Based Prioritization. Outreach follows clinical urgency, not alphabet order.
• Multi-Channel Engagement. SMS, portal, IVR, and live outreach in one orchestration layer.
• Quality Lift. Directly supports HEDIS and chronic care gap closure.
• Closed Loop. Tracks whether outreach improved labs, vitals, and adherence.