Care Management
Proactive, AI-driven care management for high-risk, complex, and chronic disease populations — ensuring your most vulnerable patients receive continuous, coordinated attention.
The Challenge
Care coordinators spend the majority of their time on administrative tasks instead of patients who need them most. High-risk and complex patients fall through the cracks between visits. Care plans go stale, follow-ups are missed, and preventable ER visits quietly drive up total cost of care — not because your team doesn't care, but because there simply aren't enough hours in the day to proactively manage thousands of complex patients.
Five Core Capabilities
Continuously scores every patient by clinical, social, and utilization risk — automatically surfacing the highest-need individuals for immediate care team action, every single day.
AI generates, updates, and tracks individualized care plans — flagging overdue interventions and recommending next actions for each patient, keeping your care team one step ahead.
Tracks CCM-eligible patients, logs care minutes automatically, and generates billing documentation — helping document care that may be reimbursable, subject to applicable rules.
Monitors hospital discharges and ER visits in real time, triggering automated follow-up workflows within required 7- and 30-day windows to prevent costly readmissions.
AI schedules and executes personalized outreach via phone, SMS, and portal — prioritizing contacts by health risk and ensuring no high-needs patient is overlooked between visits.
Care Programs Supported
ROI: 10-Provider Clinic
| Metric | Before Unity | After Unity |
|---|---|---|
| High-Risk Patients Reached | 34% | 98% ↑ |
| CCM Value/Year | $42K | $222K ↑ |
| Care Plan Completion | 61% | 92% ↑ |
| Missed Follow-Ups | High | −68% ↓ |
Explore Other Modules
All eight modules share the same AI engine, patient data, and action pipeline.
Reach every high-risk patient.
Every day. Automatically.
We'll show you exactly how Unity's Care Management module works for your patient population.
Built for HIPAA · Aligned with SOC 2-type controls · FHIR R4 Ready · ROI in 90 Days