AI Navigator for Value-Based Healthcare

In a 50,000-member cohort study, NightingaleMD closed 75% of open HEDIS gaps while maintaining 92% patient satisfaction. The system escalates to clinical staff when medical judgment is required—combining automation efficiency with clinical expertise.

75%
Gap Closure Rate
$450
PMPY Revenue Lift
24/7
Availability
30+
Languages
Schedule Demo View Clinical Outcomes
HIPAA Compliant
SOC 2 Type II
15+ EHR Integrations
AI
Gap Analysis
Care Plans
Scheduling
Escalation
Analytics
Data Enrichment

Florence AI Navigator

Evidence-based gap identification
Population health management
Clinical escalation protocols
Real-time performance metrics

Closes 3 of 4 open HEDIS gaps—validated in a 50k-member record review

Systematic approach to quality measure closure with documented outcomes

Clinical Performance Metrics

75%

Gap Closure Rate

100%

Population Coverage

70%

Cost Reduction

Data from Q1 2026 multi-site deployment, n=50,000 members

EHR-Integrated Analysis

Reviews complete medical records to identify documented and suspected gaps per NCQA specifications

Multi-Modal Outreach

Contact attempts via voice, text, and secure messaging. Average 3.2 attempts per successful closure

Direct Scheduling

Integrates with provider scheduling systems. 68% same-week appointment availability achieved

Claims Validation

Real-time verification through claims data and lab results. 96% accuracy in gap closure confirmation

Medicare Advantage HEDIS Measures We Close

50+
HEDIS Measures Supported
15+
Triple-Weighted Measures
75%
Average Closure Rate
24/7
Automated Outreach

Financial Impact Analysis

50,000
Annual Gaps Closed 37,500
Quality Bonus Revenue $2.7M
Net ROI 1,800%

Based on CMS 5-star quality bonus payments and typical MA contract rates

Clinical Workflow Integration

Evidence-based escalation protocols ensure appropriate resource allocation

Resource Optimization Model

AI Navigator

90%

Routine gap identification, appointment scheduling, medication adherence follow-up

Care Coordinators

7%

Complex scheduling, SDOH barriers, member advocacy

Clinical Nurses

2%

Health assessments, care plan modifications, clinical education

Physicians

0.5%

Complex medical decisions, urgent interventions

Comprehensive Care Coordination

Beyond gap closure: Managing transitions and chronic conditions

Integrated Care Navigation

Centralized hub for member interactions with intelligent routing to appropriate clinical resources

2M+ Members Managed
15+ Care Pathways
92% Satisfaction Score

Post-Acute Management

24-hour post-discharge contact (87% success rate)
Medication reconciliation per Joint Commission standards
Home health coordination with preferred providers
30-day readmission reduction: 23% improvement

Chronic Care Support

Monthly check-ins (CPT 99490 compliant)
Symptom tracking with escalation protocols
Care plan adherence monitoring
Provider collaboration portal

24/7 Clinical Support

Replaces traditional nurse lines (90% cost reduction)
Schmitt-Thompson protocol integration
Evidence-based health education
Crisis intervention with warm handoffs

SDOH Navigation

Transportation coordination (Z59.5)
Food insecurity screening (Z59.4)
Housing instability support (Z59.0)
Community resource database integration

For Value-Based Care Organizations

Clinical outcomes data from current implementations

Quality Performance Impact

In a 12-month deployment across 3 ACOs, participating practices achieved:

$450 PMPY Revenue Increase
90% Administrative Time Saved

Scalable Implementation

Manage entire attributed populations without proportional staff increases

Clinical Focus

Physicians report 3+ hours/week reclaimed for direct patient care

Performance Analytics

Real-time dashboards aligned with CMS quality reporting requirements

Payer Alignment

Documented quality improvements strengthen contract negotiations

Risk Mitigation

23% reduction in preventable readmissions within 90 days

Implementation Timeline

1

Assessment

Week 1

2

EHR Integration

Week 2-3

3

Validation

Week 3-4

4

Go-Live

Day 30

Supercharge Your Care Navigators

"Florence's surgical outreach handles 80% of repetitive tasks. She finds all alternate phone numbers through data enrichment, speaks the member's preferred language from 30+ options, and builds rapport by remembering personal context—so our navigators focus on complex cases that truly need human expertise."
  • Automates routine scheduling – Florence books appointments without human intervention
  • Eliminates no-show chasing – AI follows up on no-shows and reschedules promptly
  • Handles low-acuity reminders – Sends medication and preventative care reminders

Medicare Advantage Performance

Documented Star Rating improvements across multiple contracts

Baseline Performance

3.5 Stars

Year 2 Results

4.5 Stars
+0.5 Average Star Increase
5% Bonus Payment Qualified
$54 PMPY Bonus (50K lives)

Triple-Weighted Measure Performance

Medication Adherence

PDC rates improved 12-18% across therapeutic classes

Care Coordination

TRC measure: 89% completion within 30 days

HEDIS Composite

15 measures averaging 75% completion

CAHPS Scores

Member experience: 92% satisfaction

Operational Efficiency

Replace fragmented vendor solutions with integrated platform

Traditional Model

  • - Nurse line utilization <1%
  • - Manual outreach to 3% of gaps
  • - Business hours only
  • - Multiple vendor contracts

NightingaleMD Platform

  • + Proactive engagement: 100% reach
  • + 75% gap closure achievement
  • + 24/7 availability
  • + Single integrated solution

Medicaid Managed Care Results

Meeting state requirements while improving member outcomes

Addressing Complex Population Needs

Contact Rates

65% successful contact rate using multi-source data verification

Language Access

30+ languages including regional dialects

SDOH Integration

Z-code capture increased 340% with systematic screening

State Compliance

Automated reporting meets evolving requirements

Hawaii Medicaid Pilot Outcomes

High-Risk Member Engagement Program

Q1-Q2 2026 deployment results

5,000 Members Enrolled
65% Contact Success
30% ED Utilization ↓
$850 PMPY Savings

Hawaii Department of Health, Q1 2026 Report

Clinical AI Architecture

Evidence-based algorithms with continuous outcome validation

Florence AI

Clinical Decision Support Engine

Trained on 10M+ clinical interactions with continuous learning from validated outcomes

Natural Language Processing

Medical terminology recognition in 30+ languages

Security & Compliance

HIPAA, SOC 2 Type II, HITRUST certified

EHR Integration

HL7 FHIR compatible with major platforms

Performance Analytics

Real-time quality measure tracking

Investment Models

Aligned with quality performance outcomes

Foundation

Core Capabilities

  • 24/7 AI Navigator access
  • Gap identification
  • Appointment scheduling
  • Multi-language support
  • Basic care coordination

Replaces traditional nurse line services

Recommended

Performance

Foundation plus:

  • Proactive gap closure campaigns
  • Full care coordination
  • Transportation coordination
  • Provider collaboration
  • Advanced analytics

Typical ROI: $450+ PMPY

Success Partnership

Shared Success Model

  • Quality bonus sharing
  • Readmission penalties
  • Star rating improvements
  • Custom metrics
  • Aligned incentives

Risk-sharing arrangement available

Pricing is PMPM-based with gain share in premium tiers

Clinical Demonstration

Experience Florence AI Navigator handling a typical member interaction

Live Demo Line

Call to experience the AI Navigator with a sample patient scenario

Margaret Fletcher Demo: 1-800-NIGHT-MD

Schedule Consultation

Review your specific quality measures and projected ROI

Request Consultation

Florence AI avatar

Florence AI Navigator

Member Interaction Example

Florence:

"Hello Mrs. Fletcher, this is Florence from your health plan. I'm calling about some important preventive care you're due for. Is this a good time to talk?"

Member:

"Yes, I got a letter about some tests I need?"

Florence:

"That's right. Looking at your records, you're due for your annual diabetes screening - an A1C test - and your mammogram. Both are covered at no cost to you. Would you like me to help schedule these appointments?"

Member:

"Yes, but I don't have transportation to get there."

Florence:

"I can help with that. Your plan includes transportation benefits. I can arrange a ride for you to and from both appointments. Dr. Chen has availability next Tuesday at 10 AM for your A1C test. Would that work for you?"

Member:

"Tuesday works. What about the mammogram?"

Florence:

"The imaging center has openings on Thursday at 2 PM or Friday at 11 AM. Which would you prefer?"

Member:

"Thursday at 2 works better for me."

Florence:

"Perfect. I've scheduled both appointments and arranged transportation. A driver will pick you up at 9:15 AM on Tuesday for your A1C test with Dr. Chen, and at 1:15 PM on Thursday for your mammogram. You'll receive text reminders the day before each appointment. Is there anything else I can help you with today?"

Outcome: 2 HEDIS gaps scheduled for closure, transportation arranged, member barrier removed

Call Duration 3:47
Gaps Addressed 2
SDOH Resolved Z59.5

Ready to Review Your Quality Performance?

Join healthcare organizations achieving measurable improvements in quality outcomes

50+ Healthcare Organizations
2M+ Members Managed
4.5 Average Star Rating
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