Follow-up care from home
Patients check in from home between visits. Your team sees what changed and calls early, with the note written at the time.
For patients whose care carries on at home.
Any patient who can share how they are doing from a phone or tablet, and whose care team wants to know before the next visit.
Patients this works well for
- High blood pressure, heart failure, or COPD
- Diabetes or kidney disease followed between visits
- Recovery at home after surgery
- Patients who can check in from a phone a few times a week
Patients better served elsewhere
- Patients just home from a hospital stay, in their first month
- One serious condition that needs a named coordinator
- Therapy patients logging exercises between sessions
- 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.
- Focused care for one serious conditionIntensive follow-up for a single high-risk condition, with a plan the whole team can see.
- Therapy tracking at homePatients report progress between therapy sessions, so adjustments happen before the next appointment.
Your team keeps the care. Hoss Care keeps the list.
The care team decides who to call and what to do. Hoss Care puts every check-in on the record and flags what changed.
What your team does
- Sets who checks in, and how often
- Calls the patients who need a call
- Reviews, edits, and signs every note
- Sends the claims when the month closes
What Hoss Care does
- Puts each check-in on the patient's record
- Flags check-ins that changed, for the nurse to review
- Suggests the follow-up note for the clinician
- 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.
From a check-in at home to a signed note.
The same three moments repeat for every patient. Each one ends on the record.
Checking in takes a few taps from the kitchen table.
Patients share how they are doing from their own phone. What they send lands on the same record your team works from.
- Check-ins on the schedule the care team sets
- Secure messages with the care team
- Video visits without a trip to the clinic
- Works on any phone or tablet
Questions practice managers ask
How does this fit into our EHR?
Check-ins, notes, and follow-up tasks land in the patient's chart in Epic, Oracle Health, or athenahealth. Your team keeps working in the record it already uses, and nothing is copied between systems by hand.
Who does the follow-ups?
Your care team does, working from a daily list sorted by who needs attention first. If you are short on staff, our clinical team can cover the list until yours is ready. Either way, every call and note is on the same record.
Does the AI decide who gets a call?
No. AI assistance flags check-ins that changed and shows why. Your nurse decides who to call, when, and what to say, and the clinician signs the note.
How does billing work?
Eligibility is checked before a patient joins. Notes are written during each follow-up. 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 care team's daily list, then the first patients. A typical go-live takes about 30 days, and we agree the date on the first call.
Fewer surprises between visits. Every check-in on the record.
Ready to know how patients are doing before they call?
See how Hoss Care runs follow-up from home on the record your team already uses.