AI Voice Care Navigator for VBC Gap Closure

Florence by NightingaleMD

The Diligent AI Voice Care Navigator for VBC Gap Closure

"Your team - everywhere, at once."

External clinical intelligence and gap facilitation—all inside your EHR.
Florence orchestrates the two economic drivers of VBC: Care & Diagnosis Gap Closure and Patient Engagement to Avoid ED Visits.

"Value-based care only works when providers do." — We make it frictionless.

10x
Faster Gap Closure
45%
ED Diversion Rate
24/7
AI Voice Engagement
See the Copilot in Action → ▶ Explore the Care Worklist

The Two Economic Drivers of VBC

Real results, not just real-time. Florence orchestrates the outcomes that matter most for Value-Based Care success.

Care & Diagnosis Gap Closure

External clinical intelligence surfaced inside your EHR. Florence facilitates HCC capture, RAF optimization, HEDIS measures, and quality gap closure—all at the point of care.

"Gaps closed, not just flagged."

AI Voice Patient Engagement

Proactive outreach via AI Voice to engage patients before issues escalate. Appointment reminders, medication adherence, and care coordination—reducing ED visits and unnecessary hospitalization.

"The patient who needed you at 3 AM? Florence was there."

External Clinical Intelligence

Chart retrieval without the chase. Secure chart extraction during live EHR sessions with an All-In-One Hub and Real-Time Status Updates.

"Document Viewer—no toggling systems."

Referral Loop Closure

From referral to resolution. Florence tracks specialist referrals, obtains external charts, and closes the loop—ensuring no patient falls through the cracks.

"Referrals tracked, charts obtained, loops closed."

Value-Based Care ROI

Measures We Move

Real quality metrics that demonstrate Florence's impact on your value-based care performance

HCC Recapture Rate

Baseline 45%
+20%
Goal 85%

AWV Completion Rate

Baseline 30%
+25%
Goal 75%

Care Gap Closure (HEDIS)

Baseline 40%
+30%
Goal 85%

ED Diversion Rate

10%
+20%
Goal 45%

TCM Follow-Up (48hr)

Baseline 35%
+35%
Goal 90%

Patient Engagement Rate

20%
+40%
Goal 80%

Florence Impact: Average 35% improvement across all quality measures within 90 days of deployment

The 5-Phase Care Worklist

End-to-End VBC Gap Closure Orchestration

From signal detection to continuous surveillance—Florence, your AI Voice Care Navigator, orchestrates every step. Click a phase to explore its capabilities.

Gap Journey: Detected → Surfaced → Addressed → Closed → Maintained
1
Trigger

Florence Capability

Signal Detection
from COOP
Workflow Initiation
Automatic activation
Living Document
VBC Process Activated
2
Pre-Encounter

Florence Capability

Multi-Channel
SMS • Voice • Chat
20+ Languages
Native engagement
Gap Pre-Identification
Surfacing before visit
3
Encounter

Florence Copilot in EHR

Care Gaps
Assessment Completion
Diagnosis
HCC • RAF • Coding
Screening
HEDIS • Quality Gaps
4
Post-Encounter

Florence Capability

Automatic Filing
To all EHR sections
Attestation Workflows
Quality measure closure
COOP Sync
Bidirectional
Referral Management
Loop closure tracking
5
Care Mgmt

Florence Capability

Longitudinal Relationship
Continuous engagement
Proactive Outreach
Early intervention
Gap Surveillance
Loops back to Trigger
1

Trigger Phase

Signal detection and workflow initiation — 10% of the lifecycle

Florence AI Capabilities

Signal Detection from COOP
Automatically detects care opportunities from your Care Orchestration Platform
Workflow Initiation
Signal Detection — Automatic workflow initiation
Living Document Created
VBC Process Activated with continuous visibility thread

COOP Signals Detected

AWV (Annual Wellness Visit)
Preventive care opportunity identified
ADT (Admission/Discharge/Transfer)
Transition of care event detected
Care Gap / HCC/RAF Opportunity
Quality measure or risk adjustment need identified
2

Pre-Encounter Phase

Patient engagement and gap surfacing — 20% of the lifecycle

Florence AI Capabilities

Multi-Channel Outreach
SMS • Voice • Chat — reaching patients where they are
20+ Languages
Native engagement in the patient's preferred language
Gap Pre-Identification
Surfacing gaps before the visit so the care team is prepared
Patient Activation
Education and preparation for the upcoming encounter

Human Actions

Patient Advocacy
Florence acts as patient advocate, coordinating care
Medication Reconciliation
Conversations to verify current medications
Transportation & Caregiver
Coordination and engagement support
3

Encounter Phase

Florence Copilot in the EHR — 40% of the lifecycle

Florence Copilot Domains

Care Gaps
Comprehensive Assessment Completion — Gap → Addressed
Diagnosis
HCC Capture • RAF Optimization • Coding Accuracy
Screening
HEDIS Measures • Preventive Care • Quality Gaps
SDOH
Social Determinants • Community Resources • Referrals
ZERO DOUBLE-ENTRY
Work in Copilot → Florence Auto-Files to EHR: Progress Notes, Medications, Problem List, Quality Attestations

Care Team Actions

Physician
Fills structured assessment in Florence Copilot — Florence nudges for completion
Navigator
Supervises remotely with real-time visibility — No need to be in room
Patient
Center of care, active participant — Florence as advocate, gaps addressed in real-time
4

Post-Encounter Phase

Automatic filing and attestation — 15% of the lifecycle

Florence AI Capabilities

Automatic Filing
Automated Write-Back to all EHR sections — eliminates copying/pasting
Attestation Workflows
Quality measure closure with validated ICD-10 and CPT-II codes
COOP Sync
All activity reported — Bidirectional synchronization

Human Actions

Chart Review
EHR Reconciliation — Document Viewer without toggling systems
Quality Attestation
HEDIS measure closure with documentation
Referral Initiation
Loop tracking started, care plan finalized
5

Care Management Phase

Continuous surveillance and relationship — 15% + LOOP

Florence AI Capabilities

Longitudinal Relationship
Continuous patient engagement over time
Proactive Outreach
Early intervention before issues escalate
Continuous Gap Surveillance
New needs detected → Loops back to TRIGGER — The continuous loop that ensures nothing falls through the cracks

Human Actions

Adherence Tracking
Care plan compliance monitoring
Referral Loop Closure
Monitoring completion of specialist referrals
Medication Adherence
Ongoing checks — Patient maintained in care plan

Three-Way Call Capability

Florence bridges patients, caregivers, and care navigators in real-time — 400+ contacts per year vs. 4 traditional visits

👤
Patient

Receives the call, shares symptoms, concerns, and daily status

👪
Caregiver

Joins when needed for context, medication verification, or support

👩‍⚕️
Care Navigator

Escalation point for clinical decisions and care coordination

Florence AI

Orchestrating the Conversation

Deep Clinical Intelligence

Condition-Specific Clinical Protocols

Deep clinical intelligence across the most common chronic conditions in value-based care

35 Languages

Click any category to explore how Florence manages each condition

Cardiovascular

5 conditions
▼
  • Congestive Heart Failure (CHF)

    Florence automates daily weight and symptom monitoring per ACC/AHA guidelines, escalating to the care team when weight gain exceeds 3 lbs in 24 hours or 5 lbs in a week. Ensures medication adherence for beta-blockers, ACE inhibitors, and diuretics while tracking fluid restriction compliance.

  • Hypertension

    Florence conducts protocol-driven blood pressure monitoring, medication adherence checks, and lifestyle coaching on diet and exercise. Automatically escalates when BP readings fall outside patient-specific target ranges, reducing ED visits and stroke risk.

  • Atrial Fibrillation

    Florence monitors anticoagulation adherence (warfarin, DOACs), tracks heart rate control, and screens for stroke symptoms using validated protocols. Coordinates INR lab scheduling and escalates when patients report palpitations, dizziness, or medication side effects.

  • Coronary Artery Disease

    Florence supports cardiac rehabilitation engagement, medication reconciliation (statins, antiplatelets), and lifestyle modification counseling. Tracks chest pain episodes and activity tolerance, escalating when anginal symptoms change or worsen.

  • Post-MI Care

    Florence guides patients through the critical 30-day post-discharge window with daily check-ins on chest pain, shortness of breath, and medication adherence. Automates cardiac rehab referral follow-up and ensures completion of post-MI quality measures.

Respiratory

4 conditions
▼
  • COPD

    Florence monitors symptom exacerbations using COPD Assessment Test (CAT) scores, tracks rescue inhaler usage, and ensures maintenance therapy adherence. Escalates when patients report increased dyspnea, sputum production, or fever—preventing costly hospitalizations.

  • Asthma

    Florence conducts asthma control assessments per NHLBI guidelines, tracks peak flow readings, and monitors controller medication adherence. Identifies trigger exposures and escalates when patients require frequent rescue inhaler use or nocturnal symptoms increase.

  • Pulmonary Fibrosis

    Florence monitors oxygen saturation, dyspnea scores, and functional status while coordinating pulmonary rehabilitation and antifibrotic medication adherence. Escalates when O2 sats drop below prescribed thresholds or patients report worsening breathlessness.

  • Sleep Apnea

    Florence ensures CPAP adherence by tracking nightly usage hours, troubleshooting mask fit issues, and monitoring daytime fatigue symptoms. Coordinates DME vendor communication and escalates when compliance falls below the 4-hour nightly threshold.

Metabolic

4 conditions
▼
  • Diabetes Type 1 & 2

    Florence automates blood glucose tracking, medication adherence monitoring (insulin, metformin, GLP-1s), and A1C lab coordination. Screens for hypo/hyperglycemia symptoms, tracks diabetic foot care, retinal exam completion, and nephropathy monitoring—closing gaps in HEDIS CDC-H9 measures.

  • Pre-Diabetes

    Florence delivers evidence-based lifestyle coaching on nutrition, physical activity, and weight loss (targeting 5-7% body weight reduction). Tracks A1C and fasting glucose trends, ensuring timely progression to DPP referrals when appropriate.

  • Obesity Management

    Florence supports patients in GLP-1 or bariatric surgery programs with weekly weight tracking, dietary adherence, physical activity goals, and side effect monitoring. Coordinates nutritionist visits and escalates when weight loss plateaus or adverse effects occur.

  • Thyroid Disorders

    Florence monitors thyroid medication adherence (levothyroxine), tracks symptom resolution (fatigue, weight changes, mood), and coordinates TSH lab draws per protocol. Escalates when patients report persistent symptoms or lab values fall outside therapeutic ranges.

Renal

3 conditions
▼
  • Chronic Kidney Disease

    Florence tracks GFR trends, monitors blood pressure control, ensures medication adherence (ACE/ARBs, phosphate binders), and coordinates nephrology follow-up. Screens for fluid overload, anemia symptoms, and metabolic bone disease complications.

  • End-Stage Renal Disease

    Florence supports dialysis patients with interdialytic weight gain monitoring, fluid restriction adherence, and vascular access site surveillance. Coordinates dialysis center communication and escalates when patients report missed treatments or access complications.

  • Dialysis Support

    Florence conducts pre- and post-dialysis check-ins, monitors for hypotension, cramping, and infection symptoms while tracking dietary phosphorus and potassium intake. Ensures transportation barriers are addressed and medication reconciliation post-dialysis is complete.

Neurological

4 conditions
▼
  • Stroke Recovery

    Florence guides post-stroke rehabilitation with daily functional assessments, medication adherence (anticoagulants, antiplatelets), and fall risk monitoring. Screens for new neurological symptoms, depression, and ensures completion of PT/OT/speech therapy appointments.

  • Parkinson's Disease

    Florence monitors motor symptom progression (tremor, rigidity, gait), medication timing adherence (levodopa schedules), and fall risk. Tracks non-motor symptoms (sleep, constipation, mood) and escalates when dyskinesias or "off" periods worsen.

  • Multiple Sclerosis

    Florence monitors symptom flares (vision changes, weakness, numbness), disease-modifying therapy adherence, and functional status. Coordinates MRI scheduling, tracks fatigue management, and escalates when relapse symptoms emerge.

  • Dementia Care

    Florence conducts cognitive screenings, monitors behavioral symptoms (agitation, wandering), and supports caregiver burden assessment with validated scales. Ensures medication adherence, coordinates memory clinic visits, and escalates safety concerns to care teams immediately.

Behavioral Health

3 conditions
▼
  • Depression

    Florence administers PHQ-9 screenings at protocol-defined intervals, monitors antidepressant adherence, and tracks therapy engagement. Escalates immediately when suicidal ideation is detected (PHQ-9 Q9 positive) or symptoms worsen despite treatment.

  • Anxiety Disorders

    Florence conducts GAD-7 assessments, monitors anxiolytic medication adherence, and supports CBT homework completion. Tracks panic attack frequency, avoidance behaviors, and escalates when symptoms interfere with daily functioning.

  • Substance Use Disorder

    Florence supports patients in MAT programs (buprenorphine, naltrexone, methadone) with daily check-ins, craving assessments, and relapse prevention coaching. Coordinates counseling appointments and escalates immediately when relapse occurs or suicidal ideation emerges.

Musculoskeletal

3 conditions
▼
  • Osteoarthritis

    Florence monitors pain levels, functional status, and medication adherence (NSAIDs, intra-articular injections, DMARDs). Supports physical therapy engagement, weight management, and escalates when pain control is inadequate or surgical referral criteria are met.

  • Rheumatoid Arthritis

    Florence tracks DMARD adherence (methotrexate, biologics), monitors for disease flares (morning stiffness, joint swelling), and coordinates rheumatology lab work (CRP, ESR). Escalates when patients report new joint involvement or medication side effects.

  • Osteoporosis

    Florence ensures bisphosphonate or RANK ligand inhibitor adherence, tracks calcium and vitamin D supplementation, and coordinates DEXA scan scheduling. Monitors for fracture risk factors (falls, height loss) and escalates when patients report bone pain or fracture.

Post-Acute

3 conditions
▼
  • Post-Surgical Care

    Florence conducts daily post-operative assessments monitoring surgical site infection signs, pain control, mobility progression, and medication adherence. Ensures wound care instructions are followed and escalates when fever, drainage, or dehiscence occurs.

  • Wound Management

    Florence tracks wound healing progression, monitors for infection signs (erythema, purulent drainage, odor), and ensures dressing change compliance. Coordinates wound care nurse visits and escalates when healing stalls or worsens.

  • Transitional Care (TCM)

    Florence executes TCM protocols within 48 hours of discharge, conducting medication reconciliation, reviewing red flag symptoms, and ensuring follow-up appointments are scheduled. Closes the "discharge to door" gap, reducing 30-day readmissions by 22-30%.

A Phased Approach to Autonomy

Start with oversight. Graduate to scale.

We meet you where you are. Begin with full human oversight and progressively scale toward autonomous AI as your team builds trust and confidence.

What Your Patients Experience

Florence doesn't just close gaps—she becomes your patients' active health advocate.

Protocol-driven outreach: Calls timed to their treatment plan
Multilingual support: 20+ languages, culturally sensitive
Consistent follow-through: Never misses a scheduled check-in
Warm handoffs: Seamless escalation to human care team when needed
Phase 1

Co-Pilot

Human in the Loop

  • CM listens to every call
  • Reviews all documentation
  • 100% Supervision
Duration: 1-3 months
Start with Co-Pilot
Phase 2

Supervised

Human on the Loop

  • Florence acts autonomously
  • CM monitors dashboard
  • 1 CM : 10-20 Calls
Duration: 3-6 months
Explore Supervised
Phase 3

Full Autonomy

Human out of the Loop

  • End-to-end routine care
  • Escalates only on risk
  • 24/7 Scale
Ongoing
Go Autonomous

How Florence Communicates

Florence's Five-Pillar Therapeutic Persona

Florence delivers chronic care management that feels human—combining comprehensive data access with empathetic conversation to transform care management.

1

Psychological Safety

Creates a judgment-free space where patients feel secure sharing concerns

  • Non-judgmental language patterns
  • Validates patient experiences
  • "Tell me more about that" prompting
2

Warmth

Conveys genuine care through tone, pacing, and personalized details

  • Remembers previous conversations
  • Adjusts pacing to patient needs
  • Uses patient's preferred name
3

Competence

Demonstrates clinical knowledge while staying within scope

  • Accurate medical terminology
  • Clear scope boundaries
  • "Let me connect you with..." when appropriate
4

Inquisitiveness

Asks thoughtful questions to understand the patient's experience

  • Open-ended questioning
  • Explores context, not just symptoms
  • "How has this affected you?" focus
5

Unfailingly Patient

Gives time for reflection and never rushes important topics

  • No time pressure cues
  • Pauses for patient processing
  • Repeats info without frustration
Florence in Action

Your AI Care Navigator, Embedded in the EHR

Florence brings clinical intelligence directly into your workflow. No portals, no toggling, no delays.

healthchart-ehr.com/patient/jane-doe
Chart
Labs
Notes
Vitals
Schedule
JD

Jane Doe

75 y/o Female • MRN: 847291 • DOB: 03/15/1950

CHF, T2DM, HTN, CKD Stage 4
High Risk Discharged

Active Problems

I50.9 Heart Failure, unspecified
E11.9 Type 2 Diabetes Mellitus
I10 Essential Hypertension
N18.4 CKD Stage 4

Upcoming Appointments

15 Feb
Cardiology Follow-up
Dr. Michael Brooks • 2:30 PM
22 Feb
Nephrology Consult
Dr. Lisa Wong • 11:00 AM

Recent Lab Results

eGFR
29 (Low)
Creatinine
2.1 (High)
HbA1c
7.2%
BNP
450 pg/mL
Potassium
4.2 mEq/L
EHR Copilot
Active
Facesheet
Transcript
Documentation
Log

Florence Summary & Agenda

Jane was discharged from Memorial Hospital 3 days ago following CHF exacerbation. Recent labs indicate CKD progression (eGFR 29). TCM follow-up required within 7 days per CMS guidelines.

Action Items:

  1. Complete TCM Day 1 outreach call
  2. Discuss recent CHF discharge and medication changes
  3. Schedule PCP follow-up within 7 days
  4. Address suspected CKD Stage 4 (eGFR 29)
ADT Alert Discharge

Discharged from Memorial Hospital - 3 days ago

Reason: CHF Exacerbation • LOS: 4 days

1 critical alert needs attention
3 care gaps need attention

Gap Journey

40% Closed
5 Detected
1 Surfaced
1 In Progress
1 Addressed
2 Closed

CKD Stage 4 Detected

eGFR 29 indicates progression • ICD-10: N18.4

TCM Follow-up Due

Post-discharge visit within 7 days required

AWV Eligible

Annual Wellness Visit due March 2026

Clinical Note

Auto-Generated

Documentation will appear here after completing a workflow.

CKD Stage 4 Filed to EHR

ICD-10 N18.4 added to problem list

2 min ago

ADT Alert Received

Discharge from Memorial Hospital

3 days ago

Lab Results Analyzed

eGFR 29 flagged as critical

3 days ago
Supervised Autonomy Dashboard
1 Care Manager : 12 Active Calls
12
Active Calls
2
Needs Review
47
Completed Today

Florence's Escalation Protocol: Safety Guardrails Built In

Every scenario has a defined response—nothing falls through the cracks

Click any row to see detailed safety protocols and audit trails.

TriggerResponseOutcome
Medical Emergency

High-risk keywords: bleeding, chest pain, falls, unresponsive

Alert RN immediately + warm transfer to clinical team

 Immediate escalation
Detailed Safety Protocol

Trigger Detection: NLP model trained on 10,000+ emergency transcripts flags critical keywords in real-time. Confidence threshold: 95%.

Response Workflow:

  • RN receives SMS + app notification within 10 seconds
  • Florence keeps patient on line while connecting RN
  • Warm handoff includes full conversation context
  • If RN doesn't respond in 60s, escalates to on-call MD

Audit Trail: Full call recording + transcript stored for 7 years (HIPAA compliant). Incident report auto-generated to Quality team within 15 minutes.

Suicidal Ideation

PHQ-9 Q9 positive, self-harm language

PHQ-9 screening protocol + RN escalation + safety plan

 Non-interruptible handoff
Detailed Safety Protocol

Trigger Detection: Any positive response to PHQ-9 Question 9 ("thoughts of self-harm") or passive language indicators ("better off without me").

Response Workflow:

  • Florence immediately administers Columbia Suicide Severity Rating Scale (C-SSRS)
  • RN joins call within 2 minutes (median response: 47 seconds)
  • Safety plan documented: support contacts, crisis hotline, emergency services if needed
  • Follow-up scheduled within 24 hours, tracked until completion

Compliance: Meets Joint Commission sentinel event reporting requirements. Behavioral health specialist notified same-day.

Elder Abuse / Neglect

Signs of abuse, financial exploitation, neglect indicators

Mandatory reporting protocol + social work referral

 Clinician + SW review
Detailed Safety Protocol

Trigger Detection: Multi-factor model assesses: unexplained injuries, caregiver control of conversation, financial concerns, hygiene/nutrition issues, isolation from family.

Response Workflow:

  • Case flagged to Social Work team within 1 hour
  • SW conducts comprehensive assessment within 48 hours
  • Mandatory state reporting filed per jurisdictional requirements (Adult Protective Services)
  • Care team coordinates with legal/compliance for documentation

Legal Compliance: Adheres to state-specific mandatory reporting laws. Full chain-of-custody documentation for potential legal proceedings.

Behavioral Crisis

Aggression, wandering/safety risk, severe agitation

Escalation flag + full transcript to care navigator

 Care manager review
Detailed Safety Protocol

Trigger Detection: Vocal stress analysis + behavioral pattern recognition. Indicators: raised voice, rapid speech, disorientation, expressed intent to leave safe environment.

Response Workflow:

  • Florence uses de-escalation techniques (validation, redirection, empathy)
  • If unsuccessful after 2 minutes, care manager joins call
  • Full transcript + sentiment analysis delivered to CM dashboard
  • CM evaluates for: medication review, environmental safety, psychiatric consult

Follow-up: Care plan updated. Follow-up call scheduled within 24-48 hours to assess resolution.

Confusion Detected

Patient unable to answer, disoriented, impaired

Request caregiver join call immediately

 Three-way call
Detailed Safety Protocol

Trigger Detection: Inability to recall basic info (name, date, address), repetitive questions, tangential responses, long pauses, or explicit statements of confusion.

Response Workflow:

  • Florence asks: "May I call [caregiver name] to join our conversation?"
  • Three-way call initiated using emergency contact on file
  • If caregiver unavailable, Florence documents observations and notifies care team
  • Care team evaluates for: cognitive decline, medication side effects, acute delirium

Clinical Follow-up: MD or NP review flagged within 24 hours. May trigger cognitive assessment (MMSE/MoCA) at next visit.

Routine Call

No flags, standard check-in

Document findings + schedule follow-up

 Auto-note to EHR
Detailed Safety Protocol

Standard Workflow: Florence completes protocol-driven assessment (symptom check, medication adherence, vital signs if applicable, appointment reminders).

Documentation:

  • Structured note auto-filed to EHR within 2 minutes of call completion
  • Includes: call duration, topics covered, patient-reported outcomes, action items
  • Care gaps closed (e.g., mammogram scheduled) reflected in quality dashboards
  • Next follow-up auto-scheduled per protocol (e.g., CHF weekly, diabetes biweekly)

Quality Assurance: 10% of routine calls randomly selected for RN quality review to maintain calibration and identify improvement opportunities.
PHQ-9 & PHQ-2 screening protocols built in
24/7 RN Oversight for all escalations
Full Audit Trail for every interaction

Seamless Integration with Your Existing Systems

Florence connects to your EHR and population health platforms—no portals, no toggling, no delays.

EHR Systems

Epic
athenahealth
eClinicalWorks
NextGen
Allscripts
MEDITECH
Oracle Health
Greenway
ModMed
AdvancedMD
DrChrono
Kareo

Population Health Platforms

Arcadia
Innovaccer
Health Catalyst
Lightbeam
Azara
Epic Healthy Planet
Salesforce Health

Clinical Data Sources

EHR/CCDA
HIE Networks
Hospital ADT
Lab Networks
Pharmacy
750K+
Clinicians Connected
147K+
Care Sites Linked

Ready to Digitize Your VBC Gap Closure?

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⚡ HEDIS Season Is Here — Organizations joining by Feb 15 will have NightingaleMD operational before March measurement deadlines. Only 3 integration slots remain for Q1.