Chronic Care Management

A care manager monitors a panel of patients with diabetes and hypertension — identifying gaps, triggering outreach, and tracking progress without leaving their daily tools.

Microsoft Teams

Care Manager — Demand Signals

Flagged Patients — Today

Patricia H., 58AI Flagged

Missed A1C check — 4 months overdue

Thomas R., 72Auto-detected

BP reading 158/95 — above threshold

Angela M., 49Pattern Detected

Missed last two appointments

Carlos D., 65AI Flagged

Medication refill not picked up

Gmail

Automated Outreach — Patricia H.

SMS Sent — 8:00 AMAuto-sent

"Hi Patricia, it's time for your A1C check. We've made it easy to schedule — reply BOOK or click here."

Patient Response — 8:47 AM

"BOOK"

System Response — 8:47 AMAuto-scheduled

"Great! You're booked for Thursday, April 17 at 10:00 AM with Dr. Rivera. We'll send a reminder."

Power Apps

Patient Pathway — Patricia H.

Diabetes Management Pathway

Annual Wellness Visit

A1C Lab WorkNext Step

Medication Review

Nutrition Counseling Referral

90-Day Follow-Up

Microsoft Teams

Care Manager — Today's Tasks

Call Thomas R. — confirm BP medication adherenceAI Generated

High

Review Angela M.'s no-show history — rescheduleAI Generated

Medium

Verify Carlos D. picked up refill

Medium

Send care plan update to Dr. Rivera (3 patients)

Low

Before

Gaps in care discovered only during annual reviews
Outreach done manually via phone calls
No centralized view of patient compliance or progress
Reactive care — problems caught late

After

Demand signals flag patients automatically when gaps appear
Outreach triggered via SMS/email — no manual effort
Care manager sees prioritized task list every morning
Proactive care — problems prevented before they escalate

"Chronic care management doesn't need a specialized platform. It needs smart workflows inside the tools your team already opens every morning."

Key Takeaway