Ongoing care for complex conditions
Monthly follow-ups for patients with two or more long-term conditions. One care plan, one care team, and one record they all open.
For patients carrying more than one condition.
Patients whose conditions overlap, and whose care involves more than one clinician, need one plan and a regular call.
Patients this works well for
- Two or more long-term conditions expected to last a year or more
- Conditions that put the patient at real risk
- Care that involves several clinicians or a pharmacy
- Patients who agree to a monthly follow-up
Patients better served elsewhere
- One serious condition that needs close follow-up
- A primary care panel where your practice is the home base
- Patients in their first month after a hospital stay
- Focused care for one serious conditionIntensive follow-up for a single high-risk condition, with a plan the whole team can see.
- Advanced primary careWhole-panel primary care, tracked by the work performed rather than a time count.
- Care after a hospital stayA follow-up call soon after discharge, a visit on the calendar, and the handoff on one record from the first day home.
Your coordinators run the month. Hoss Care keeps the plan in one place.
The care team builds the plan and makes the calls. Hoss Care keeps the plan, the list, and the notes on one record.
What your team does
- Builds the care plan with the patient
- Makes the monthly follow-up call
- Coordinates with specialists and the pharmacy
- Reviews, edits, and signs every note
What Hoss Care does
- Keeps one care plan on the record for the whole team
- Lists who is due a follow-up this week
- Suggests the monthly note from the call, for review
- Prepares the claim with the signed note attached
AI assistance in Hoss Care is advisory. It suggests and flags; your clinicians review, edit, and sign, and your staff submit.
One plan, a call each month, and the team in the loop.
The plan is written once and followed every month, with every call and referral on the record.
Everyone who is due, on one list.
Your coordinators open one list in the morning and see who is due, who changed, and which notes are waiting for a signature.
- Who is due a follow-up this week
- Notes waiting for the clinician to sign
- Referrals sent and replies received
- A missed call rebooked from the same screen
Questions practice managers ask
How does this fit into our EHR?
The care plan, the monthly notes, and the follow-up tasks live in the patient's chart in Epic, Oracle Health, or athenahealth. Your team keeps working in the record it already uses.
Who does the monthly follow-ups?
Your care coordinators do, working from a list of who is due this week. If you are short on staff, our clinical team can cover the list until yours is ready. Every call and note is on the same record either way.
Which patients qualify?
Patients with two or more long-term conditions expected to last a year or more, where those conditions put the patient at real risk. Eligibility is checked before the first follow-up, so only patients who qualify join.
How does billing work?
Eligibility is checked before the first follow-up. Notes are written during each call. When the month closes, the claim is prepared with the signed note attached, ready for your billing team to send.
How long does it take to go live?
The EHR connection comes first, then the list of patients who qualify, then the first month of calls. A typical go-live takes about 30 days.
One plan and a monthly call on the list for each patient. Every call on the record.
Ready to give every complex patient one plan?
See how Hoss Care runs monthly follow-ups for your complex patients, on the record your team already uses.