Aligned patients
42
Demo cohortNeeds navigator action
7
3 high priorityCare plans current
88%
Caregiver outreach due
5
Next 7 daysPatients needing attention
| Patient | GUIDE status | Current signal | Owner |
|---|---|---|---|
| Maria Lopez Synthetic • 79 • moderate complexity | Aligned | ED transition | J. Carter |
| Robert Kim | Aligned | Caregiver burden ↑ | M. Singh |
Today’s operating queue
!
Review Maria’s ED discharge
NowMedication changes and follow-up tasks
!
Schedule home assessment
Due✓
Caregiver education
On trackMaria Lopez Synthetic patient
79 • Medicare FFS • Moderate dementia • Daughter/caregiver: Elena Lopez
High-priority event: Emergency department discharge reported. Medication reconciliation, transition follow-up, and care-plan review are pending.
Current state
Needs review
Caregiver burden
Elevated
Next GUIDE action
Transition
Longitudinal timeline
Today • ED discharge received
Caregiver reports fall evaluation; patient returned home. Discharge document pending.
6 days ago • Caregiver check-in
Increasing nighttime agitation and fatigue.
3 weeks ago • Transportation referral closed
Community partner confirmed upcoming rides.
Familiar Agent briefing
What changed: ED event after a fall. Possible gap: discharge medications are not yet reconciled against the current list.
Suggested actions: obtain discharge summary; reconcile medication list; confirm PCP follow-up; reassess fall/home-safety risk; check caregiver capacity; update care plan if needed.
Human approval: required before clinical or external-care instructions are sent.
Suggested actions: obtain discharge summary; reconcile medication list; confirm PCP follow-up; reassess fall/home-safety risk; check caregiver capacity; update care plan if needed.
Human approval: required before clinical or external-care instructions are sent.
Eligibility & alignment
✓
Dementia confirmed
Complete✓
Medicare A & B / primary payer
Complete✓
Residence eligible
Complete✓
Consent & voluntary alignment
CompleteNine GUIDE service domains
✓
Comprehensive assessment
Current✓
Person-centered care plan
Review due!
Ongoing monitoring & support
Event open!
Medication reconciliation
Pending✓
24/7 access
Active!
Care coordination / transitions
Pending✓
Referrals & community supports
Active✓
Caregiver education & support
Active✓
Respite services
EligiblePerson-centered care plan
Clinician review dueRemain safely at home and reduce avoidable emergency visits.
Reduce nighttime caregiving load and schedule regular respite.
PCP follow-up after ED; medication review; fall-risk review.
AI draft controls
Draft only. The agent can summarize and propose edits. It cannot diagnose, prescribe, change medications, or finalize the clinical plan.
✓
Sources linked to patient record
Traceable✓
Human approval required
Logged24/7 support intake
Elena Lopez — caregiver
“Mom fell. The ER sent her home and changed one of her pills.”
Transition workflow
!
Obtain discharge summary
Open!
Reconcile medication list
Clinician!
Confirm PCP follow-up
Navigator!
Reassess home/fall safety
Care teamTransportation
RideWell Community
Referral closedRespite
Home Relief Services
Awaiting availabilityMeals
Local Meals Network
Potential referralPatient quality of life
PROMIS-10
Baseline capturedCaregiver impact
ZBI-22
Elevated burdenHigh-risk medication
Review
Transition pendingReference architecture
DCP STAFF / CAREGIVER / PARTNERS
│
▼
┌─────────────────────────────────────────────┐
│ Experience Layer │
│ Navigator • Clinician • Caregiver • Partner │
└──────────────────────┬──────────────────────┘
▼
┌─────────────────────────────────────────────┐
│ Care Orchestration │
│ Familiar Agent • GUIDE Rules • Tasks │
│ Alerts • Human approvals │
└───────────────┬─────────────────────────────┘
▼
┌─────────────────────────────────────────────┐
│ Longitudinal Care Data + AI Services │
│ Assessments • Care plan • Meds • Events │
│ Referrals • Summaries • Drafting │
└───────────────┬─────────────────────────────┘
▼
┌─────────────────────────────────────────────┐
│ Integration Gateway │
│ FHIR/SMART • HL7 ADT • APIs • Documents │
└───────────────┬─────────────────────────────┘
▼
DCP CEHRT / Hospitals / PCP / Partners
CROSS-CUTTING: HIPAA/BAA • encryption • RBAC/MFA
consent • tenant isolation • audit trail • backups