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Category: Clinical Operations  ·  Signals: Care plan · Referral graph · Outreach attempts · Documentation state
Keep the patient, the chart, and the next step in lockstep across every transition.

Overview

The Care Coordinator Agent keeps the patient, the chart, and the next step in lockstep. It runs continuously against the care plan, triggers outreach when a milestone slips, and generates the documentation that proves the loop closed. Every coordination action — outreach attempted, referral sent, screener refreshed — is documented to the chart with rationale.

How this agent works

Configuration

This agent takes the following configuration from your practice settings:
  • Practice care-plan templates by program
  • In-network and partner referral graph
  • Outreach channels and compliance caps (SMS, email, phone)
  • Closed-loop documentation requirements

Execution

At runtime, the agent executes the following steps:
  1. Maintains the care plan as the source of truth across transitions
  2. Triggers outreach for next-step appointments and screener refreshes
  3. Generates referrals and tracks closed-loop confirmation
  4. Surfaces handoff risk to the care team with rationale
  5. Documents every coordination action in the chart

Composable experts

The Care Coordinator Agent bundles the following experts from the registry:
ExpertRole
Care Plan ExpertPractice template adherence and milestone reasoning
Referral Graph ExpertNetwork logic, partner preferences, capacity reads
Outreach ExpertChannel selection and timing within compliance caps
Closed-Loop Audit ExpertReceipt, scheduling, completion, documentation

Typical use cases

  • Close referral loops the practice can prove to a payer
  • Re-engage patients who drift off the care plan, before they no-show
  • Surface care plans the clinician hasn’t touched in weeks
  • Document every coordination action without an admin staffer

Compliance & safety guarantees

  • Outreach is always within practice-configured compliance caps
  • Referrals are tracked to closed-loop confirmation or escalation
  • Care plan milestones are tracked against a documented template

Tags

Coordination · Care plan · Referral · Outreach · Closed-loop

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