Around 1490, Leonardo drew a man standing inside a circle and a square. The drawing is a study of proportion: the arm against the height, the hand against the face, every measurement against the whole body. Nothing is drawn alone.

Care works best the same way, and it is rarely delivered like that. A patient's blood pressure lives in one system, their mood in another note, and their follow-up in a phone call nobody wrote down. Each piece can be correct and the whole can still be wrong.

This page follows one patient through Hoss Care. It shows where AI assistance helps and where a clinician decides, and what changes for patients, care teams, and the health plans that pay for care. There are no customer names or invented figures here. Where we cite industry data, the source is linked.

01The whole person

Conditions connect, so the record has to.

Most adults who need ongoing care are not living with one condition. The CDC reports that three in four American adults have at least one chronic condition, and over half have two or more (CDC, About Chronic Diseases, industry data).

Those conditions affect each other. High blood pressure and diabetes share risk and medication decisions. Low mood makes it harder to keep up with either. A team that sees only one of them makes reasonable choices that miss the patient.

On Hoss Care, each condition is followed under its own care service, such as diabetes care, ongoing care for complex conditions, or integrated behavioral health, and all of them write to one patient record. The nurse following blood pressure can see last week's behavioral health note. The physician signing the diabetes follow-up can see both.

Leonardo da Vinci, Studies of the heart, lungs, liver, and spleen, c. 1508Organs drawn in relation to each other, the way conditions affect each other.

Figure 1Connected conditions, followed under their own care services, all on one record.

02The patient journey

Care is a loop, not a line.

Most software draws care as a line: referral, visit, bill, done. Patients do not experience it that way. They come back, sometimes on schedule and sometimes because something changed.

On Hoss Care, a referral from the EHR becomes an intake, with booking, forms, and insurance checks finished before the patient arrives. The visit happens on video or in person, and the note, orders, and signatures are captured during it. Follow-ups run between visits, each written to the same record. Once a year, an annual wellness visit looks at the whole picture again, and whatever it finds goes back to the care team.

Two kinds of marks sit on this loop. At some steps, AI assistance flags something for a person to look at, such as a missing intake field or an overdue follow-up. At others, a person makes a decision: a clinician signs a note, or a nurse calls a patient. The flag always comes first and never replaces the decision.

Figure 2One patient's loop through Hoss Care. AI assistance flags; people decide; the loop returns to the care team instead of ending at the bill.

03Between visits

Most care happens when nobody is in the room.

A visit lasts minutes. The weeks after it decide whether the plan works. That is where follow-up care from home, care after a hospital stay, and therapy tracking at home do their work.

The care team sees this as a panel, not a pile. Every patient sits in one of four states: overdue, due, in follow-up, or stable. The panel ranks who needs attention today, so a nurse starts with the patient whose check-in changed, not the one whose name comes first.

Jan Steen, The Doctor and His Patient, c. 1663Care at the bedside, between the formal visits.

Outreach closes the gaps the panel shows. When a patient is due for a preventive check, a reminder goes out by text or phone, and the reply lands in the same thread on the record. If a practice uses HossClinical, licensed nurses and coordinators work this panel inside the same account, under the practice's own clinicians.

After a hospital stay, the first days at home carry the most risk. The discharge arrives from the EHR, and a follow-up call is placed on the panel before the patient is home. What the patient said, and any change to medications, is written to the record before the next visit.

The panel does not decide who is sick. It shows what is due and what changed, and a person decides what to do.

Figure 3The care team's panel in four states. Outreach moves patients from overdue back into care, and stable patients return to the panel when their next check is due.

04AI assistance

AI suggests. Clinicians decide.

Hoss Care uses AI assistance in the background of the work. It reads signals from three places: data from the EHR, what was captured during the visit, and check-ins from home. It compares them against the requirements of the care service the patient is under and the patient's own context: conditions, medications, and history.

What comes out is a suggestion or a flag, nothing more. A suggestion might be a draft line for a note. A flag might be a care gap, a missing signature, or documentation that does not yet meet what the care service requires. Before a claim is submitted, AI assistance checks the note against those requirements, so a missing signature holds back one claim before it is sent, not after it is denied.

Every output is advisory. A clinician reviews it, edits it if needed, and signs; staff then submit the claim. The AI does not write the final note, decide care, or send anything to a payer. When a flag is wrong, the clinician dismisses it, and the dismissal is kept on the record.

A flag is a question. The signature is the answer.

1 · Signals inEHR recordThe visitCheck-ins from home

2 · ChecksAgainst the care service's requirements and the patient's context: conditions, medications, history

3 · SuggestionA suggested note line, a flagged care gap, a missing signature

Advisory gate: nothing passes without a clinician

4 · ClinicianReviewEditSignor dismiss, which is also kept on the record

5 · On the recordThe signed note, the claim staff submit from it, and who reviewed what. The signed record becomes context next time.

Figure 4How AI assistance fits. Signals are checked against requirements and patient context, and the result is a suggestion or a flag. Nothing passes the advisory gate without a clinician's review and signature.

05Integration

Your EHR stays. The work connects to it.

Hospitals and clinics already run an EHR, and most have spent years shaping it. Hoss Care does not replace it. HossConnect sits between the EHR and everything else, keeping a two-way sync with Epic, Oracle Health, athenahealth, eClinicalWorks, NextGen, and others.

Data moves both ways. Demographics, appointments, referrals, and eligibility come in from the EHR. Notes, orders, and care plans go back to it. Check-ins from the patient app arrive on the patient timeline, and claims move to billing without anyone retyping them.

Because the record is shared, nothing has to be reconciled at the end of the week. A note signed in Hoss Care is in the EHR when the physician opens the chart. Hoss Care works with any EHR, and a typical go-live takes 30 days.

Figure 5HossConnect keeps a two-way sync with the EHR and routes the same record to the care team, the patient, and billing.

06Payers and value-based care

Documented care is care you can show.

Health plans pay for care they can see. Under fee-for-service, each claim needs to match a complete, signed note. Under value-based care, they need to know quality measures were met across a whole population: blood pressure control, diabetes checks, preventive visits completed.

Both depend on documentation made during the work, not reconstructed afterward. On Hoss Care every action carries a timestamp, the person responsible, and the outcome. Notes feed quality measures, measures roll up by site and care team, and when a plan asks for evidence the record exports with the notes attached.

Value-based care makes this sharper. When a practice shares in savings or risk, it needs to know where it stands during the year, not after the reporting deadline, so a gap in diabetes checks can still be closed with outreach.

If it was done, it is on the record. If it is on the record, it can be shown.

Documented care

Each with who, when, and the outcome

Fee-for-service

One claim per visit, built from the signed note

Value-based contracts

Measures and care gaps, tracked across the panel during the year

When a payer asks

The record behind every claim and measure

Figure 6One body of documented care serves both payment models: claim by claim for fee-for-service, and measure by measure for value-based care.

07What changes

What changes for patients, care teams, and payers.

Connected care is not a feature any one group sees on its own. It shows up differently depending on where you stand.

Patients

One threadMessages, reminders, and video visits arrive in one place, from people who can see their whole history.
Care between visitsA check-in from home reaches the care team the same morning, and a change gets a reply.
Fewer repeatsIntake details and history carry forward, so nobody asks for them again at every step.
Preventive care on timeA reminder arrives when a check is due, and booking it takes one reply.

Care teams

One screen to start the dayThe panel ranks who needs attention, so the morning starts with the patient whose situation changed.
Notes done at the visitNotes, orders, and signatures are captured during the visit; AI assistance suggests and flags, the clinician signs.
Less adminTeams report 70–90% less admin work once copying between systems and rebuilding notes afterward stops.
Help when hiring is hardHossClinical nurses and coordinators can work the follow-up queue inside the same account.

Payers and health plans

Claims that match notesEach claim is built from a signed note and checked before staff submit it.
Measures you can traceQuality measures roll up from documented care, and each number links back to the work behind it.
Evidence on requestThe record exports with notes attached, for review or audit.
Fits both modelsThe same documentation supports fee-for-service and value-based arrangements.

The patient should never be the one carrying their record between rooms.

08Getting started

Start with one care service, on the EHR you already run.

Most organizations begin with a single care service, often follow-up care from home or care after a hospital stay, and add others once the team is comfortable. The platform runs on a 99.9% uptime target, connects to any EHR, and typically goes live in about 30 days.

Implementation follows the order of this page: the EHR connection first, then the care team's panel and workflows, then billing. Staff train on their own patients, and AI assistance is switched on with the clinicians who will review its flags.

A demo walks through the loop on this page with your workflows in mind: how a referral arrives, how follow-ups are staffed, where AI assistance flags, and how the claim leaves.

Book a demo See how it works

How connected care works for the patient, the care team, and the payer