Marco Diaz
Chronic Disease Management · Eligible · 63 yo · Medicaid ID MCD-120000023
Current Care Plan
Open Care Plan Copilot →Review CHF medication adherence
Marco will schedule and attend a follow-up appointment with his primary care physician (PCP) to review his CHF management and medication plan by October 31, 2026.
Assessment
Open Assessment Copilot →Comprehensive Reassessment — COMPLETED
Tasks, Alerts & Care Gaps
Workflow Orchestration
Rules + SLA engineRules fire only after a care manager approves something. Each item is routed to an owning team and given an SLA clock; anything past SLA escalates to the supervisor queue.
Automation history
- Care plan item approvedSep 16, 2026, 11:07 AM
- Assist Marco in scheduling the appointment with his PCP for CHF management. → routed to Care Manager, due Sep 17, 2026Turn approved interventions into owned tasks · owner set by the rule that created it
- Provide a reminder one week before the appointment to ensure attendance. → routed to Care Manager, due Sep 17, 2026Turn approved interventions into owned tasks · owner set by the rule that created it
- Prepare a list of questions and concerns for Marco to discuss during the appointment. → routed to Care Manager, due Sep 17, 2026Turn approved interventions into owned tasks · owner set by the rule that created it
- Send updated care plan to PCP and member → routed to Care Coordination, due Sep 19, 2026Distribute the updated care plan · owner set by the rule that created it
- Assist Marco in scheduling the appointment with his PCP for CHF management. → routed to Care Manager, due Sep 17, 2026
- Assessment completedSep 16, 2026, 11:06 AM
- Transmit completed Comprehensive Reassessment and care plan to PCP → routed to Care Coordination, due Sep 19, 2026Transmit assessment + care plan to PCP · cross-provider coordination — matched "pcp"
- Schedule next comprehensive reassessment → routed to Scheduling Team, due Sep 30, 2026Reset the reassessment clock · appointment scheduling — matched "schedule"
Reassessment due date moved to 2027-03-15 (Reset the reassessment clock)
- Transmit completed Comprehensive Reassessment and care plan to PCP → routed to Care Coordination, due Sep 19, 2026
- SLA breach sweepSep 15, 2026, 11:24 AM
- SLA breach: Review CHF medication adherence → routed to Supervisor — Dana Whitfield, due Sep 15, 2026Escalate on SLA breach · escalations route to the supervisor queue
- SLA breach: Review CHF medication adherence → routed to Supervisor — Dana Whitfield, due Sep 15, 2026
Active rules (7) — configuration, not code
- Transmit assessment + care plan to PCPAssessment completed
The completed assessment and care plan have to reach the PCP; today that is a manually generated letter.
- Reset the reassessment clockAssessment completed
Completing a reassessment books the next one and moves the case due date out, instead of leaving it on a spreadsheet.
- Behavioral health co-management reviewAssessment completed
Co-managed behavioral health cases get a second reviewer rather than routing everything back to the primary CM.
- Turn approved interventions into owned tasksCare plan item approved
Each intervention on an approved care plan item becomes a routed, SLA-tracked task rather than free text inside a PDF.
- Distribute the updated care planCare plan item approved
An approved change to the care plan triggers distribution to the PCP and the member.
- Supervisor review on escalationAI suggestion approved
An approved escalation opens a short-SLA supervisor review instead of relying on someone noticing it.
- Care gap outreach on high-risk membersAI suggestion approved
An approved care gap on a high-risk member schedules member outreach so the gap has an owner and a clock.
Notes → Actions
No notes yet.
Timeline
TASK: Review CHF medication adherence
Case opened in CCA
Claim received — office visit, evaluation & management
Prescription fill recorded
ESCALATION: SLA breach: Review CHF medication adherence
TASK: Transmit completed Comprehensive Reassessment and care plan to PCP
TASK: Schedule next comprehensive reassessment
TASK: Assist Marco in scheduling the appointment with his PCP for CHF management.
TASK: Provide a reminder one week before the appointment to ensure attendance.
TASK: Prepare a list of questions and concerns for Marco to discuss during the appointment.
TASK: Send updated care plan to PCP and member