Complex patients, followed up between visits
Internists carry the most complex panels in primary care. Hoss Care keeps every condition on one record, brings check-ins from home into the chart, and suggests the note during the visit for the clinician to review and sign.
What an internal medicine day runs into.
Internal medicine carries the heaviest long-term condition load of any specialty, and most of it lives between visits.
A panel too large to watch by hand
A panel in the thousands with rising long-term conditions means care gaps are found late, if at all.
In practiceA patient with heart failure misses two follow-ups, and the gap shows up at the next admission.
Notes that eat the evening
Every long-term condition needs its own documentation, and most of it is written after the last patient leaves.
In practiceThe physician finishes charting at nine, for visits that ended at five.
Annual wellness visits that never get booked
Most patients who are due for a yearly visit are never scheduled for one, so the gaps stay open another year.
In practiceThe recall list exists, but nobody has time to work it.
Specialists and primary care out of sync
Referrals go out and results come back to different inboxes, so plans conflict and tests get repeated.
In practiceThe cardiologist changes a dose, and the internist learns about it from the patient a month later.
Built for complex panels and the teams that follow them.
One plan per patient, every condition on one record. AI assistance suggests and flags; your clinicians review, edit, and sign.
Every condition on one record
Diabetes, hypertension, COPD, heart failure, and the rest of the panel followed in one place, with one plan per patient.
In practiceThe nurse opens a patient and sees every condition, every follow-up, and what is due next.
- EHR
- Care team
- Follow-ups
Wellness visits that actually happen
Patients due for a yearly visit are found, scheduled, and prepared for, and the gaps are closed before they leave.
In practiceThe front desk works a recall list the platform keeps current instead of one built by hand.
- Quality measures
- Care coordination
- Notes
Follow-up between visits, documented
Check-ins from home and follow-ups are captured during the work, with the claim prepared from the signed note.
In practiceA blood pressure check-in from home lands on the chart with a suggested note for the nurse to review and sign.
- Check-ins from home
- Documentation
- Claims
Built for the complexity of internal medicine.
Every feature is designed around patients with several conditions and the teams that follow them.
- Works with the EHR you already use
- Notes written during the work
- One plan for patients with several conditions
- Care gaps found before the visit
- Check-ins that need attention are flagged for review
- HIPAA-compliant messaging
- Claims prepared with the note attached
- Annual wellness visit workflows
Care services your team can run for complex patients.
Follow-ups, check-ins from home, and wellness visits your team already provides, documented while the work happens so the record supports the claim.
- 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.
- Follow-up care from homePatients check in from home between visits. Your team sees what changed, acts early, and the record is written as it happens.
- Annual wellness visitsThe yearly visit prepared for, risks flagged, and the gaps closed before the patient leaves.
- 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.
- Integrated behavioral healthScreening, follow-up, and care coordination for mind and body in the same visit workflow.
One plan for every condition. Every follow-up on the record.
Ready to follow up every patient on your panel?
See how Hoss Care helps internal medicine practices follow complex patients between visits and finish the documentation during the day.