Extend care beyond the next visit
Support Chronic Care Management (CCM) programs with regular follow-up, structured patient-reported information and attention focused where it is needed.
SOLUTION
Clinical follow-up between visits
Scheduled contact with every enrolled patient, with alerts that bring those who need review to the team’s attention.
Scheduled check-ins for every enrolled patient
Each contact records symptoms and changes since the last one, along with condition-specific data such as weight, home measurements or medication adherence. Administrative steps, such as upcoming appointments, can be handled in the same conversation.
Alerts based on defined escalation criteria
Responses are checked against the escalation criteria, such as combinations of symptoms or readings outside a set range, and core safety criteria always apply. The care team reviews each alert and decides what happens next, from another contact to an in-person assessment.
Each patient’s evolution over time
Every interaction is added to the patient’s record, showing how symptoms and readings evolve over weeks and months. Each new alert is read against that history, not as an isolated value.
Contact frequency adjusted to each patient’s status
The team can increase the frequency when changes call for closer attention, or reduce it while the patient remains stable. Inclusion, pause and exit criteria are set in the protocol.
chronic and long-term WORKFLOWS
From follow-up between appointments to prioritised review
Protocols grounded in clinical practice guidelines and refined across previous implementations.
End-stage kidney disease follow-up
Follow-up of patients with end-stage chronic kidney disease.
Type 2 diabetes follow-up
Follow-up of patients with type 2 diabetes.
Anxiety and depression assessment (Goldberg)
Records anxiety and depression symptoms using the Goldberg scale.
Emotional wellbeing follow-up
Regular follow-up of the patient’s emotional state.
Heart failure self-care assessment (EHFScBS)
Assesses self-care habits in patients with heart failure using the EHFScBS scale.
Quality of life assessment (EQ-5D-5L)
Measures health status and quality of life with the EQ-5D-5L questionnaire.
Pacemaker remote transmission support
Supports patients during pacemaker data transmission and records any incidents for the team.
Hospital-at-home follow-up
Follow-up of symptoms, medication and wellbeing in patients receiving hospital-at-home care.
Palliative care follow-up
Follow-up of symptoms, medication and wellbeing in patients receiving palliative care.
Systemic lupus erythematosus follow-up
Follow-up of symptoms, medication and wellbeing in patients with moderate to severe lupus.
Inflammatory bowel disease follow-up
Follow-up of symptoms, medication and wellbeing in patients with intestinal disease.
Advanced chronic kidney disease follow-up
Follow-up of symptoms suggesting progression in patients with advanced chronic kidney disease.
Severe asthma follow-up
Follow-up of symptoms, disease control, medication and wellbeing in patients with severe asthma.
Complex chronic patient follow-up
Follow-up of symptoms, medication and wellbeing in complex chronic patients, mainly with COPD and heart failure.
Heart failure follow-up
Regular follow-up to identify exacerbations or situations that need intervention in patients with heart failure.
61%
lower combined risk of all-cause death or hospitalisation for heart failure versus the control group.
Continuous follow-up helps care teams identify patient deterioration and intervene when needed.
Improved clinical outcomes
Large public hospital
+7,13
improvement in KCCQ-12 quality-of-life score among heart failure patients over 12 months.
Regular follow-up supports symptom monitoring and self-management, helping patients manage their condition between visits.
Better patient quality of life
Large public hospital
95.3%
Average engagement across 50,000+ follow-up contacts in 9 long-term programmes.
Patients continue engaging with automated follow-up, even across long-term care programmes.
Sustained patient engagement
EVIDENCE
Measurable impact on patient care.
Success Story
Patient reach and engagement with clinical AI Report
94.1%
Reach and engagement
Success Story
Closer monitoring in hypertrophic cardiomyopathy | Large public university hospital
Success Story
Early complication detection in prostate cancer | Large public university hospital
Success Story
Early deterioration detection in severe asthma | Large public university hospital
Success Story
Preventing emergency visits in chronic care | Mid-sized public university hospital
“We can prioritise follow-up and adjust the frequency of visits according to each patient’s clinical situation.”
BENEFITS
Keep care connected as patient needs change
Earlier Detection & Intervention
Identify changes in symptoms and patient-reported health status between visits, enabling timely clinical intervention.
Better Clinical Outcomes
Support proactive disease management and help reduce the risk of avoidable deterioration and hospitalizations.
Improved Patient Engagement
Keep patients engaged in their care plans through regular, accessible follow-up by phone and SMS.
Stronger Continuity of Care
Maintain consistent follow-up between appointments, supporting long-term disease management and treatment adherence.
Greater Clinical Efficiency
Reduce routine monitoring workload and help care teams focus on patients who need clinical attention.
RELATED CAPABILITIES
Chronic and long-term follow-up connects with the rest of the care pathway
Long-term follow-up can overlap with admissions, tests and treatment changes.
Treatment support and adherence
Collection of information on medication taking, tolerability and support needs throughout treatment.
Perioperative care
Contact before the procedure to go over preparation and collect the information set out in the protocol.
Post-discharge care
Post-discharge follow-up during the window defined by the department, with symptom collection and alert criteria.