AI Care Management

Identify high-priority patients, understand common risk drivers, and simulate AI outreach. Deterministic demonstration scores — not clinical predictions.

SYNTHETIC DEMO DATA

FromToOrganizationRisk

Total patients (filtered)

1,248

Synthetic cohort

Critical

2% of total

High risk

111

9% of total

Moderate

332

27% of total

Low risk

779

62% of total

Outreach completion

High/critical reached in window

Risk distribution

2026-01-01 → 2026-10-19

Top common risk drivers

Share of 137 high/critical patients

Multiple chronic conditions100%

Repeated ER visits99%

Recent hospital admissions89%

Outstanding care gaps88%

Medication non-adherence83%

Missed appointments82%

Risk trend over time

Each point re-scores its own sub-window

Patient prioritization (deterministic score)

1248 patients · SYNTHETIC DEMO DATA

Patient	Age	Score	Level	Contributing factors	Adm.	ER	Med adherence	Next action
F · Sunshine Health Plan	88	96	Critical	Repeated ER visits, Recent hospital admissions	3	4	44%	Post-discharge follow-up
F · Bayview Community Care	90	94	Critical	Repeated ER visits, Recent hospital admissions	2	8	10%	Post-discharge follow-up
M · Coastal Medicare Advantage	78	92	Critical	Recent hospital admissions, Repeated ER visits	2	3	0%	Post-discharge follow-up
F · Bayview Community Care	92	92	Critical	Repeated ER visits, Recent hospital admissions	2	5	38%	Post-discharge follow-up
F · Sunshine Health Plan	58	91	Critical	Repeated ER visits, Recent hospital admissions	2	5	11%	Post-discharge follow-up
M · Bayview Community Care	96	90	Critical	Repeated ER visits, Recent hospital admissions	2	4	33%	Post-discharge follow-up
M · Coastal Medicare Advantage	88	90	Critical	Recent hospital admissions, Repeated ER visits	3	3	56%	Post-discharge follow-up
F · Coastal Medicare Advantage	74	88	Critical	Recent hospital admissions, Repeated ER visits	2	3	22%	Post-discharge follow-up
M · Bayview Community Care	55	88	Critical	Repeated ER visits, Multiple chronic conditions	1	3	38%	Post-discharge follow-up
M · Bayview Community Care	64	88	Critical	Repeated ER visits, Recent hospital admissions	2	5	10%	Post-discharge follow-up
F · Bayview Community Care	77	87	Critical	Repeated ER visits, Recent hospital admissions	4	5	50%	Post-discharge follow-up
F · Coastal Medicare Advantage	68	87	Critical	Repeated ER visits, Multiple chronic conditions	1	3	33%	Post-discharge follow-up
F · Bayview Community Care	73	86	Critical	Repeated ER visits, Recent hospital admissions	3	4	25%	Post-discharge follow-up
F · Bayview Community Care	61	86	Critical	Repeated ER visits, Recent hospital admissions	4	4	57%	Post-discharge follow-up
M · Bayview Community Care	94	85	Critical	Repeated ER visits, Multiple chronic conditions	1	6	33%	Post-discharge follow-up
F · Coastal Medicare Advantage	62	85	Critical	Repeated ER visits, Recent hospital admissions	2	8	63%	Post-discharge follow-up
F · Bayview Community Care	77	85	Critical	Repeated ER visits, Recent hospital admissions	2	4	89%	Post-discharge follow-up
M · Bayview Community Care	67	83	Critical	Recent hospital admissions, Repeated ER visits	2	3	56%	Post-discharge follow-up
M · Bayview Community Care	72	83	Critical	Repeated ER visits, Medication non-adherence	1	6	20%	Post-discharge follow-up
F · Coastal Medicare Advantage	89	82	Critical	Repeated ER visits, Medication non-adherence	1	6	0%	Medication review

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Scoring configuration (demo)

Illustrative weights — not clinically validated. Administrators only.

Read-only for Executive

Repeated ER visits (max)Recent hospital admissions (max)Medication non-adherence (max)Multiple chronic conditions (max)Overdue discharge follow-up (max)Missed appointments (max)Outstanding care gaps (max)

moderate thresholdhigh thresholdcritical threshold

AI Care Assistant

Answers from synthetic records + your filters

Window: 2026-01-01 → 2026-10-19

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