Chronic Patient Management

In Collaboration with Pacific Heights Medical Group

Meet Josh, an 82-year-old patient who manages several chronic conditions while living alone with limited access to transportation.

Managing patients like Josh, with multiple chronic conditions, is a complex and time-consuming task for primary care teams. Our AI-powered assistant, Sam, integrates directly into the patient’s medical record, enabling a full understanding of the patient’s medical history, medications, appointments and outstanding orders.

Sam ensures that patients remain engaged with their care plans by automating vital sign monitoring and alerts, providing 24/7 assistance, sending timely medication reminders, and keeping his care team and family informed when additional support or intervention is necessary.

Demo Walkthrough Guide

Patient Context

Josh manages multiple health conditions including hypertension, heart disease, obesity, asthma and others. He has been prescribed with a variety of daily medications to manage these conditions. Living alone, his transportation options are limited due to a broken car, so he relies on taxis and paratransit services. While his daughter Jane offers some support from out of town, Josh struggles to pick up his prescriptions regularly and stay on track with taking his weight and blood pressure measurements daily due to his current situation.

How to Begin Your Demo

  • Ad Hoc Patient Questions

    As Josh’s AI-powered assistant, Sam is at his fingertips 24/7 for any questions. This conversation highlights the ability for Sam to triage ad hoc communications at anytime with patients reaching out to us directly.

    Once you are finished speaking with Sam, you can view the conversation insights here.

    Start Josh's chronic care check-in

  • Daughter Notification

    Josh is responsible for taking his prescribed medications daily and refilling prescriptions at his pharmacy. If he needs assistance with refills or new prescriptions, Sam will notify his daughter Jane to ensure he receives the support needed. As Jane, this conversation serves as a notification regarding your father’s current oversight in picking up his medication.

    Once you are finished speaking with Sam, you can view the conversation insights here.

    Start Jane's medication alert engagement

  • Provider Notification

    Josh’s blood pressure readings have consistently exceeded 130/80 for one month and now require escalation to his primary care physician. As Dr. Demas, this conversation serves as a reminder of your patient's current health insights and areas of concern.

    You can view our demo family conversation here.

    Start physician's patient blood pressure elevation engagement

  • Weight Monitoring

    While monitoring Josh’s vital signs, Sam is able to intervene when required based on the care plan. In this case, Josh must take his weight daily. If his weight exceeds 180 lbs, he is required to take an additional 40 mg dose of Furosemide tablet. Sam will also remind Josh—and his daughter—if a measurement is missed. As Josh, this conversation serves as a notification following your recent weigh-in, which indicated a weight exceeding 180 lbs.

    Once you are finished speaking with Sam, you can view the conversation insights here.

    Start Josh's weight alert engagement

  • Blood Pressure Alert

    While monitoring Josh’s vital signs, Sam is able to intervene when required based on the care plan. In this case, Josh is required to monitor his blood pressure daily. If his reading exceeds 130/80, he should retake the measurement to confirm accuracy. If it remains high for five consecutive days, the readings will be escalated to the physician. Sam will follow up with Josh and his daughter if a measurement is missed. As Josh, this conversation serves as a reminder to retake his measurement at the earliest opportunity.

    Once you are finished speaking with Sam, you can view the conversation insights here.

    Start Josh's retake reminder engagement

Pre-Approved Knowledge Base

RAG (Retrieval Augmented Generation) combines retrieval and generation techniques to enhance AI interactions. RAG documents allows our system to access and retrieve relevant information from specific sources and then generate accurate, contextually appropriate responses.

For inquiries related to the topics below, Sam will provide responses based on pre-approved sources, ensuring accurate and prompt assistance.

By automating routine monitoring and providing 24/7 support, our solution takes a significant administrative load off the primary care team, allowing them to focus on critical escalation points in patient care. This approach enhances patient safety, promotes adherence to care plans, and ensures that both physicians and family members are well-informed and engaged.