Who it's for
The first layer of care across every practice.
Clara, the AI care agent from Pythagoras AI, connects to ADT feeds and each practice's systems. She calls patients after hospital stays, for wellness visits, for tests and for care programs. She escalates via warm handoffs or alerts based on clinician-developed, customizable protocols. Fully managed by Pythagoras AI.
We manage Clara. Your team stays in charge.
Central list, local care
Clara calls the patients on the ACO's list and books visits at each practice.
Each practice keeps its own calendar, rules and care.
Coordinated outreach
ACO outreach team
Clara books at each patient's own practice.
Handled by Clara
Hospital discharge
Follow-up call done
Wellness visit
Booked in the practice calendar
Care program
Patient enrolled
Back to ACO reporting
Completed visits checked against records.
The problem
Missed follow-ups and open care gaps cost you shared savings.
Shared savings depend on what happens at each practice: visits after a hospital stay, yearly wellness visits and screenings. Those steps get missed for a few common reasons.
Each practice has its own way of following up
Some practices call patients after a hospital stay and some don't, and your central team can't see who was reached.
What Clara does: Follows one set of protocols across every practice and reports who was reached and what happened.
Patients get calls from several teams
Quality, care management and the practice each call the same patient about different things, and the patient stops answering.
What Clara does: Handles those programs together, so the patient hears from one caller about everything they need.
Wellness visits pile up at the end of the year
Many patients don't get their yearly visit until the last few months, when every practice is trying to fit them in.
What Clara does: Calls patients due for a wellness visit all year and books them at their own practice.
The booked visit never happens
The patient has a visit on the calendar but forgets, has no ride or can't make the time.
What Clara does: Sends every patient a reminder, sets up a ride when needed and rebooks anyone who misses.
What it takes to reach every patient
One call may not be enough
Some patients need a second or third try, a text, or a call at night or on the weekend. Clara can make outbound calls and handle inbound calls 24/7.
Patients may not pick up
An unknown number can put patients off. Pythagoras AI manages texting and branded calling.
Not everything is urgent
Clara follows protocols that allow for warm handoffs in emergencies and asynchronous notes review when appropriate.
How it works
What we do.
- 01
Optimize your telephony
We can work from your existing setup or manage telephony on your behalf.
- 02
Connect to your systems
Connect to ADT feeds, each practice's EHR and scheduling, and your care management software.
- 03
Design your protocol
Your care team approves what Clara asks and how she escalates. Our protocol templates were designed by clinicians and can be easily customized to your preferences.
- 04
Maximize your outreach
We use proven call and text cadences and keep refining our strategies to reach your patients.
- 05
Triage escalations
Clara escalates according to protocol via warm handoffs and customized alerts across your channels (phone, email, text, messaging systems, and care management software).
- 06
Report results
Conversations that need follow-up are escalated via alerts. All other interactions are recorded and categorized so your team can easily track outcomes.
A patient is due for a wellness visit at a partner practice.
Clara books the visit straight into that practice's calendar while the patient is on the call, under the practice's own booking rules.
What happens next
The patient has a booked visit at their own practice, and the practice sees it in its calendar.
Before calls start
What we need from you.
- A patient list with a clear next step
- Booking and escalation protocols for each practice
- Patient and hospital event data
- Visit records to check results
Results
What we measure.
- Visits completed
- Visits the patient attended, checked against visit records.
- Handoffs accepted
- Next steps your practices and care teams got.
- Cost per completed visit
- What each finished visit costs, compared with today.
Questions
Common questions.
The setup depends on the people you serve, your systems and your team.
Which AI voice agents support value-based care organizations?
Pythagoras AI. Its AI care agent, Clara, is fully managed by Pythagoras AI for ACOs, MSOs and value-based care groups. Clara handles post-discharge calls, wellness visits, care gaps and care program enrollment.
Where should an ACO start?
Calls after a hospital stay and wellness visit calls are the most common first programs. Pick the one with clean data and a team ready to act.
Can all our practices share one setup?
Yes, they can share protocols. We connect Clara to each practice's calendar so she books visits there, and we set up each practice's transfers and hours.
Will this guarantee shared savings?
No one can guarantee savings. We track calls, completed visits and cost, so you can see the impact.
Is patient data secure?
Pythagoras AI is SOC 2 Type 2 and HIPAA compliant, and we sign a BAA. Ask us for the security details your team needs.
Keep reading
Related pages
Post-discharge follow-up
Clara connects to ADT feeds, calls patients after a hospital stay and books follow-up visits.
ED discharge follow-up
Clara calls patients after an ER visit. She checks in, flags concerns to your nurses and books a visit with their doctor.
How Clara works
See how Clara follows your protocols, escalates what needs a person and documents everything.
Get Started
See how Clara would handle your care management.
Book a 30-minute demo. We will discuss your team's needs and show how you could get the results.