Diabetes management
Check-ins on glucose logs, medication adherence, and foot/eye-care goals.
Clinical Intelligence Agent
Chronic Care Manager Agent
An agent that runs structured monthly check-ins with chronic-care patients, tracks care-plan adherence, and escalates anything concerning to a nurse — so care teams cover a full CCM panel without dropping the patients who need attention.
Nurse-in-the-loopEscalation guardrailsFHIR R4Audit Logged
Trusted by global innovators
The manual burden today
Chronic Care Management is high-value but hard to scale — patients with two or more chronic conditions need documented monthly outreach, care-plan review, and 20+ minutes of coordination. The agent runs that routine layer: structured monthly check-ins on the patient's preferred channel, medication and self-management adherence checks, and interaction time captured as documented CCM time. Stable patients are handled and logged; anything crossing a threshold escalates to a nurse with full context. It handles the routine and hands off exceptions — it does not manage care on its own.
Architecture
How the CCM agent runs check-ins across channels, evaluates responses against escalation rules, and writes documented time and updates back to the EHR.
Key Capabilities
CCM check-ins, adherence tracking, and safe escalation — with billable time captured and a nurse on the exceptions.
Structured CCM check-ins
Monthly check-ins by phone, SMS, or app with condition-aware questions for diabetes, hypertension, CHF, or COPD — not a generic script.
Care-plan adherence tracking
Tracks medication adherence, home readings, appointments, and self-management goals against the care plan and flags gaps.
Escalation guardrails
Rule-based thresholds route red-flag responses — chest pain, worsening symptoms, missed critical meds — to a nurse with full context.
Documented, billable time
Captures interaction time and structured notes so documentation supports CPT 99490/99439 without hand-writing every call.
FHIR care-plan write-back
Reads and updates FHIR CarePlan, Goal, and Observation resources, tailored to the patient's conditions and RPM data where available.
Where it runs
Deployment scenarios
Heart failure follow-up
Tracks weight, symptoms, and diuretic adherence, escalating decompensation signs.
Hypertension programs
Reviews home blood-pressure readings and medication adherence.
COPD coordination
Checks symptom changes, inhaler use, and action-plan steps.
Expected impact
Directional — depends on panel size and escalation thresholds.
Full panel
Monthly CCM check-ins covered at scale
Documented
Interaction time captured for CCM billing
Escalated
Red-flag responses routed to a nurse in real time
Compliance-First Healthcare App Development Services Backed by Global Standards
15-Minute Scoping Call01
HIPAA
Health Insurance Portability and Accountability Act
Protect PHI with privacy-first architecture, encrypted storage and transmission, strict access controls, and traceable audit logs.
02
GDPR
General Data Protection Regulation
Implement lawful consent flows, data minimization, retention controls, and secure processing for sensitive health data.
03
FHIR
Fast Healthcare Interoperability Resources
Enable standardized health data exchange across apps, care teams, and systems through robust FHIR-ready APIs.
04
HL7
Health Level Seven International
Support enterprise-grade interoperability with HL7-based integrations for records, events, and clinical messaging workflows.
05
HITRUST
Health Information Trust Alliance
Align security programs to healthcare-specific control and risk management practices trusted by providers and ecosystem partners.
06
HITECH
Health Information Technology for Economic and Clinical Health Act
Design with breach notification readiness, digital record safeguards, and operational controls that support regulated care programs.
07
SaMD
FDA Software as a Medical Device
Plan software quality, traceability, and documentation pathways for products that may require SaMD review and submission.
08
MDR (EU)
Medical Device Regulation (European Union)
Prepare EU market-ready processes for risk classification, evidence tracking, and lifecycle governance under MDR expectations.
09
SAMHSA
Substance Abuse and Mental Health Services Administration
Apply confidentiality controls and consent-aware sharing models for behavioral and mental health data experiences.
Standards we build against
Standards & interoperability
FHIRCPTHIPAASOC 2TCPA
How It Works
From scheduled check-in to nurse escalation
The agent runs the check-in, evaluates responses against guardrails, escalates exceptions to a nurse, and writes documented time and updates back to the EHR.
1.
Capture — scheduled check-in
On the CCM cadence, the agent reaches the patient on their preferred channel and runs a structured, care-plan-specific check-in.
Multi-channel intake
2.
Processing — adherence + guardrails
Responses are checked against the care plan and escalation rules; stable results are documented, red-flags routed for human review.
Rule-based escalation
3.
Action — resolve or escalate to nurse
Routine check-ins are completed and logged; anything concerning escalates to a nurse with full context.
Nurse-in-the-loop
4.
Write-back — CarePlan + billable time
Updates FHIR CarePlan, Goal, and Observation resources, records billable CCM time, and logs to an immutable audit trail.
Audit logged
Related proof
Read Case StudyLera Health: compliant women's health platform
Related proof of compliant, AI-assisted delivery — not this exact agent. Lera Health shows how we build patient-facing, AI-assisted care on a privacy-first data layer.
Compliance & Guardrails
15-Minute Scoping CallAutomates the routine, escalates the risk
A patient-facing agent in chronic care needs hard escalation rules and a human on anything clinical.
PHI handling
PHI stays inside your compliance boundary under a BAA, encrypted end to end, with per-patient consent.
Nurse-in-the-loop
Nurses own every clinical decision; the agent coordinates the routine layer, it does not diagnose or treat.
Explainability
Every escalation shows which response and rule triggered it.
Audit logging
Check-ins, escalations, and captured time are logged immutably for billing and compliance.
Frequently Asked Questions
Yes — PHI stays inside your compliance boundary under a BAA, encrypted in transit and at rest, and every check-in, escalation, and care-plan update is audit-logged.
Ready to scale your CCM program?
Tell us your target conditions and EHR. We'll return an architecture review and a phased plan with escalation rules and documentation built in from the start.
contact@agnotic.com
Partnerships
contact@agnotic.com