Know which chronic patients are about to fall silent. Reach them before the gap becomes a readmission.
Patientrig scores every patient in your attributed panel for appointment-miss and Rx refill-gap risk — then triggers the right outreach channel before the care gap opens wide enough to matter.
Chronic patients miss their follow-up within 90 days of discharge — and most care teams don't know until it's too late.
Published chronic disease management literature, composite rangeOf CHF readmissions are associated with a medication refill gap in the preceding 30 days.
CHF readmission literature, composite rangeTypical VBC penalty exposure per unreached attributed patient across common pay-for-performance contract structures.
VBC contract modeling, based on published MSSP and PCMH structuresFrom patient data to care intervention in under 24 hours
A read-only EHR connection is all it takes. Patientrig ingests, scores, and queues interventions without disrupting your existing workflows.
We establish a read-only connection to your EHR — ADT events, claims history, and Rx fill records. No write-back, no workflow disruption. Data refreshes daily.
Epic, Cerner, Athena supportedOur risk model analyzes appointment-adherence signals, refill history, and social determinants proxies to produce a ranked patient queue per care team — updated every 24 hours.
Separate models per disease populationThe care coordinator reviews the queue and confirms interventions — or lets the automated channel fire. SMS to the patient, call queue for the nurse, alert to the pharmacist.
3 outreach channels per patientBuilt for the four chronic conditions that drive 80% of VBC penalties
Metformin non-adherence accelerates HbA1c drift. Most care teams don't know until the 90-day lab shows the change — weeks after the refill gap opened.
Diabetes use caseCHF patients re-admitted within 30 days if they miss their ACE inhibitor refill. The pharmacy gap usually opens on day 12-18, well before the readmission trigger.
CHF use caseCOPD exacerbations spike seasonally. Patients who miss their pulmonology follow-up in fall have 2x the winter admission rate. The pattern is predictable — and preventable.
COPD use caseHEDIS BP control measures are binary: controlled or not. But the 60-day window where a patient stops reporting readings entirely is where intervention matters most.
Hypertension use caseWhat coordinators are saying
"We had a manual process — a coordinator ran a report on Mondays and called the highest-risk patients. Patientrig replaced that whole workflow and we now reach three times as many patients per week."
"The pharmacy alert channel was the thing nobody else had. Half our CHF patients weren't picking up calls but they responded to the text their pharmacist sent. That one channel closed 60 refill gaps in the first month."