Built for the four chronic conditions that drive 80% of VBC penalties
Each disease population has distinct outreach timing, refill patterns, and intervention channels. Generic engagement tools miss this. Patientrig has a separate risk model for each.
Metformin non-adherence drifts slowly. The HbA1c won't show it for 90 days.
The challenge with Type 2 diabetes outreach is the lag between the care gap and the visible consequence. A patient stops picking up their Metformin in month 3 of a medication change, but their next HbA1c isn't until month 6. By then, the drift has already happened.
Patientrig watches the refill sequence, not the lab result. When the fill interval starts lengthening — the patient who used to refill on day 27 is now waiting until day 38 — that's the signal. An automated SMS reaches them before the 90-day lab shows the problem.
The ACE inhibitor refill gap opens on day 12–18. Nobody knows until day 29.
CHF readmission rates are tracked obsessively. But the pharmacy refill gap that predicts that readmission — the ACE inhibitor or beta-blocker not picked up 12–18 days after discharge — isn't tracked by anyone. The care team finds out when the patient presents at the ED.
For CHF, the pharmacy alert channel is the most effective intervention. Half of CHF patients with refill gaps respond to a pharmacist-initiated follow-up at pickup — not to a nurse call, not to a patient SMS. Patientrig knows this and routes the alert accordingly.
COPD exacerbations spike seasonally. The pattern is predictable 8 weeks before winter admission.
COPD exacerbation risk is the most seasonal of the four chronic conditions. Patients who miss their pulmonology follow-up in October have approximately twice the winter admission rate of those who don't. The pattern holds across five years of claims data and is predictable from appointment history alone.
The intervention for COPD is earlier than for CHF or diabetes — ideally in September and October, not when the exacerbation is starting. Patientrig flags COPD patients for late-summer outreach based on the prior year's follow-up pattern, not just the current gap.
HEDIS BP control is binary. The 60-day silence window is where care falls apart.
HEDIS BP control measures track whether a patient's blood pressure is controlled at the point of measurement. What they don't track is the patient who stops reporting readings for 60 days — not because their BP is fine, but because they've disengaged from monitoring entirely.
Patientrig tracks the reporting pattern, not just the reading. When a hypertension patient who has been reporting consistently goes silent for 45–60 days, that's the intervention window. An SMS reminder re-establishes the monitoring habit before the annual measurement point captures the deterioration.
What health systems see in the first 90 days
Early outcomes from Patientrig pilots. These reflect actual care coordinator activity, refill closure events, and appointment completion data — not modeled projections.