A comprehensive healthcare data system designed for telephonic Annual Wellness Visits in rural Appalachia, enabling better care coordination, patient outreach, and improved health outcomes.
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Identify patients due for Annual Wellness Visits and prioritize outreach based on risk factors, distance to healthcare facilities, and past engagement.
Manage telehealth AWV appointments for patients with transportation barriers or in remote areas with limited healthcare access.
Identify care gaps across patient populations in rural Appalachia and prioritize interventions based on clinical impact and resource constraints.
Track social determinants of health specific to rural Appalachian communities and connect patients with appropriate community resources.
Monitor medication adherence and identify barriers specific to rural populations, such as pharmacy access or affordability concerns.
Optimize care team workflows for telephonic AWVs to maximize efficiency and ensure comprehensive health assessments.