Focused care for one serious condition
Close follow-up for patients with a single high-risk condition. One plan the specialist and primary care both open, with every follow-up on the record.
For the one condition that needs the most attention.
Some patients have one serious condition that needs a named coordinator and frequent follow-up, more than a monthly call.
Patients this works well for
- One high-risk long-term condition
- A condition expected to last three months or more
- A condition that puts the patient at real risk
- Patients who agree to regular follow-ups
Patients better served elsewhere
- Two or more long-term conditions under one plan
- A whole primary care panel tracked as one
- Patients in their first month after a hospital stay
- Ongoing care for complex conditionsMonthly follow-ups for patients with two or more long-term conditions, with one care plan and one care team on the same record.
- 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.
One coordinator who knows the patient. One plan everyone sees.
Your team names the coordinator and makes the calls. Hoss Care keeps the plan where the specialist and primary care can both open it.
What your team does
- Names one coordinator for the patient
- Agrees the plan between specialist and primary care
- Makes the follow-up calls and visits
- Reviews, edits, and signs every note
What Hoss Care does
- Keeps the plan where every clinician involved can open it
- Lists who is due a follow-up, and who was missed
- Suggests the note from each follow-up, 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.
Close follow-up, without anyone losing the thread.
One plan, a follow-up every few weeks, and changes that reach everyone before the next call.
Everything about the one condition, in one place.
The coordinator, the specialist, and the primary care team open the same plan and see what is done, what is in progress, and what is due.
- A named coordinator on every patient
- Specialist and primary care on the same plan
- Follow-ups on a schedule, with a note each time
- A missed call rebooked from the same screen
Questions practice managers ask
How is this different from ongoing care for complex conditions?
Focused care follows one high-risk condition closely, often led by a specialist. Ongoing care for complex conditions follows two or more conditions under one plan. A patient is on one of them in a given month, and we help you sort the panel.
Who coordinates the patient's care?
One named coordinator on your team, working from a list of who is due. The specialist and the primary care team open the same plan, so a change made by one is seen by the other.
How does billing work?
Eligibility is checked before the first follow-up. Notes are written during each follow-up, and 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 follow-ups. A typical go-live takes about 30 days.
One condition, followed closely. Every follow-up on the record.
Ready to give one condition the attention it needs?
See how Hoss Care runs focused follow-ups on the record your team already uses.