We built GAIN on our deep experience managing reimbursable chronic care (>400K patient encounters) with tele-RNs for dozens of provider organizations. Using millions of minutes of patient-nurse conversations that have driven proven outcomes in diabetes and reduced total cost of care ~30%, GAIN is perfectly tuned to supercharge today’s population health teams / care managers.At its core, GAIN is an integrated system of i) RN-patient relationship building, via a welcome call, monthly checkins and escalations as needed, and ii) agentic AI modules, each tested thoroughly for clinical effectiveness, to handle lower-level assessments and gaps-in-care tasks. Agents effectively handle:
Whether a cardiovascular disease assessment or COPD dialogue/survey, GAIN agents will output a Red, Yellow or Green score for each patient. Then RNs will review and provide prompt triage or follow-up in case of Red or Yellow zones. In all cases, the RN will review GAIN’s suggested, evidence-based SOAP note and communicate with the patient while planning the next month’s follow-ups. Patient communications happen via phone or text with both RN and the AI agent assistant. All communications are fully tracked and documented in EHRs with financial claims information auto-imported to EHR RCM systems via our broad integrations (Epic, Cerner, eCW, athena, Veradigm and others etc.). The result: GAIN amplifies RNs’ reach to ~8x more patients so that nurses can spend more time building human relationships or performing higher-judgement triage and/or health coaching.
Following compliant enrollment into GAIN via our enrollers, an eligible patient is scheduled for a welcome call with their assigned nurse (CircleLink RN or clinic team). On this call the nurse will introduce the preventive care program and set the care plan. This includes:
The CircleLink RN or clinic team would also select the next month’s module: an individualized, condition-specific assessment or clinical goal to accomplish, like Gap-in-Care screening. GAIN turns up the volume here by deploying a virtual nurse AI assistant to call or message with the patient and report back to the CircleLink RN or clinic staff. Topics include:
Above: AI Agents amplify clinical staff by taking over certain patient outreach
Making this even more robust, GAIN’s evidence-based protocols will use patient responses to determine if the patient is in the Green, Yellow or Red zones. GAIN will then suggest next steps in a SOAP note (Subjective Objective Assessment Plan) for RN review/customization. In the case of a patient in the Red zone or Yellow zone, an RN is available 24/7 for Triage and/or timely follow-up.
Above: Example of Agent-Patient conversation and resulting SOAP documentation. GAIN determined a "Yellow" zone here.
Interested in learning more? Join our October 23rd webinar for an in-depth demo.
