10decodersCare gaps that surface themselves.
Care managers at a community behavioral health center tracked assessment schedules in spreadsheets and chased patients by phone, with no way to see who was falling behind. 10decoders built a care coordination agent that watches every assessment schedule, ranks who needs attention, and dispatches personalised outreach to a filtered batch in one action.
The patients who slip are the ones nobody is looking at.
Coordination at the center ran on spreadsheets and calendar reminders. Care managers held complex behavioral health and IDD care plans across their caseloads, and knowing who had missed an assessment meant remembering to check. Outreach was a phone call, so it happened when a care manager had a gap in the day — which meant follow-up timing varied with workload rather than with clinical need, and nothing recorded whether the patient had actually been reached. Clinical leadership had no current picture of caseload health without someone assembling one by hand.
10decoders built a care coordination agent that removes the remembering. It monitors each patient's assessment schedule continuously, calculates how far overdue each one is, and assigns a priority tier from days overdue and gap severity — so the care manager opens a list that is already sorted by who needs attention. Outreach is a template and a filtered batch: personalised messages go out in one action, with delivery confirmed and recurring campaigns scheduled to run unattended. Four live KPI tiles give supervisors a caseload pulse without a report request.
From remembering to check to being told what needs action.
The challenge
- Assessment schedules tracked in spreadsheets and calendar reminders across care managers
- No automated detection of an overdue assessment, and no ranking of who was most at risk
- Outreach handled entirely by individual phone calls, with no delivery confirmation
- Follow-up timing driven by care manager availability rather than by clinical urgency
- No live view of caseload health — a status picture required manual chart aggregation
Our approach
- Continuous monitoring of every patient's assessment schedule, with days overdue calculated
- A priority tier derived from days overdue, condition type and care gap severity
- Templated outreach dispatched to a filtered batch, personalised per patient and confirmed
- Scheduled recurring campaigns that run unattended, so reminders do not wait on availability
- Four live KPI tiles giving leadership a current caseload picture with no report request
Built for the caseload, not just the calendar.
Detection and outreach are the same problem. Knowing who slipped is only useful if reaching them is a single action.
Automated gap detection
Each patient's assessment schedule is monitored continuously, with overdue records surfaced and counted rather than discovered during a chart review.
Priority ranking
A tier is calculated from days overdue, condition type and gap severity, so limited daily outreach capacity goes to the highest-risk patients first.
Batch outreach dispatch
A template and a filtered batch send personalised messages to every patient in the group, with the send confirmed rather than assumed.
Scheduled campaigns
Recurring reminder campaigns are scheduled in advance and dispatched unattended, so outreach does not compete with clinical duties for a care manager's day.
Live caseload KPIs
Overdue assessments, today's appointments, pending referrals and engagement rate update automatically at the top of every session.
Assignment & access control
Each patient is assigned to a care manager under role-based access — managers see their own caseload, supervisors see the aggregate, and patient data stays compartmentalised.
Four capabilities. One agent.
The agent covers the path from a schedule slipping to a patient being reached and the reach being recorded.
Care gap detection & priority scoring
Monitors each patient's assessment schedule, calculates how far overdue it is, and assigns a dynamic priority tier — surfacing the most at-risk patients at the top of the list without any manual chart review.
Automated outreach system
One-action dispatch of personalised messages to a filtered patient batch, with per-patient personalisation, delivery confirmation and a scheduled queue for recurring campaigns.
Real-time caseload dashboard
Four always-current KPI tiles — overdue assessments, today's appointments, pending referrals and patient engagement — giving clinical leadership a live caseload picture with no manual aggregation.
Care manager assignment & RBAC
Per-patient care manager assignment under full role-based access control — filtered caseload views for managers, aggregate views for supervisors, and appropriate data compartmentalisation across the team.
From a slipped schedule to a patient reached.
Four steps take an overdue assessment through detection, ranking, outreach and confirmation.
Monitor schedules
Every patient's assessment schedule is watched continuously, with overdue records detected as they occur rather than at review time.
Rank by priority
Days overdue, condition type and gap severity produce a tier, and the caseload list sorts itself by who needs attention.
Dispatch outreach
The care manager picks a template and a filtered batch, and personalised messages go out in a single action.
Confirm & track
Delivery is confirmed, engagement updates on the KPI tiles, and scheduled campaigns continue unattended.
What each role actually sees.
Care managers work their own caseload; supervisors see the aggregate across the team. The agent scopes both from the same data.
An action-ready caseload
- A care gaps list filtered to their own assigned patients, sorted by priority tier
- Quick actions for appointment reminders and assessment due notices across the batch
- A scheduled message queue showing upcoming automated batches with time, template and count
- Patient-level detail — last assessment, days overdue, next appointment and direct actions
Aggregate caseload health
- The full care gaps view across every care manager, paginated and filterable
- Live KPI tiles covering overdue assessments, pending referrals, appointments and engagement
- Cross-manager outreach visibility — scheduled queues, delivery confirmations and trends
- A priority-sorted view showing where the highest-risk patients sit, to redirect capacity
Coordination that does not depend on remembering.
What changed for each group — and the controls the platform is built on.
Told, not searching
The session starts with a list already sorted by who needs attention, and reaching that group is one action rather than an afternoon of calls — returning coordination time to direct clinical work.
Caseload health, always current
The KPI tiles replace the report request. Overdue assessments, pending referrals and engagement stay visible continuously, so capacity can be moved before a gap becomes an incident.
Compartmentalised by design
Role-based access keeps each care manager scoped to their own caseload in an access-controlled environment with NDA-bound teams. Source code and IP ownership remain with the client throughout.
