Care Coordination Agent

Care Coordination

Overview

Why hire this digital worker?

Care doesn't stop when the visit ends, but the follow-through usually does. Patients miss follow-ups, skip steps in their care plan, and fall through the gaps between teams, while staff don't have the hours to chase every reminder, check-in and referral by hand. Coordinators spend their day on manual outreach and admin instead of the patients who need attention most, and the highest-risk patients are often the ones who go quiet. The result is missed follow-ups, avoidable readmissions and worse outcomes.

How they help?

Better outcomes, fewer gaps: keeps every patient on their care plan with timely reminders, check-ins and follow-ups.
Reaches the patients who go quiet: proactive, personalised outreach so high-risk patients don't fall through the cracks.
Coordinators freed for care: takes manual outreach and admin off the team so they focus on the patients who need them.
Risk surfaced early: flags patient risk indicators before appointments so clinicians arrive prepared.
Smoother referrals: routes and tracks referrals between teams so nothing stalls in a handoff.
Fewer readmissions and no-shows: post-visit follow-up keeps recovery and attendance on track.

Key Features

Care Coordination Agent Skills:

The Care Coordination Agent keeps patients connected to their care between visits. It runs proactive outreach, follow-ups and care-plan check-ins, coordinates referrals across teams, and surfaces risk before it escalates, across each patient's preferred channels.

Sends appointment reminders and proactive post-visit follow-ups
Runs personalised care-plan check-ins and adherence nudges
Reaches out to high-risk and overdue patients automatically
Surfaces patient risk indicators to clinicians before appointments
Routes and tracks referrals between care teams
Coordinates pre-visit preparation and required steps
Captures patient-reported updates and routes concerns to staff
Personalises outreach to each patient's history and condition
Works across the patient's preferred channels, in their language

Built-in integrations & safeguards

Integrations:

EHR / clinical records for care plans, history and risk data
Scheduling / practice management
Patient communication channels: SMS, email, portal, voice
Referral management
Care management / population health platform
Risk stratification and analytics data

Safeguards:

Patient-data protection: handles health data within privacy law and consent
Clinical boundary: never gives medical advice or triage, routes clinical concerns to staff
Immediate escalation of urgent or red-flag patient responses to a human
Identity verification before sharing or updating records
No invented clinical information or guidance, grounded in live records
Full audit trail and performance tracking

Agent Information

Use case

Care Coordination

Go-live duration

4 Weeks