Immediate follow-up after missed appointments to understand barriers and reschedule patients.

Follow-up on specialist referrals to ensure patients complete recommended care.

Re-engage patients who haven't been seen in months to bring them back into care.

A supportive check-in to identify early signs of financial or benefit instability in patients affected by recent SNAP, Medicaid, or tax policy changes.

Regular review of care plan goals, progress tracking, and engagement reinforcement to ensure optimal health outcomes.

Support for proper medication use, addressing concerns and side effects to ensure treatment effectiveness.

Regular mental health monitoring using the PHQ-9 assessment to track depression symptoms and ensure timely interventions.

Regular assessment of pain levels, patterns, and impact on daily activities to optimize pain management strategies.

Monitor sleep patterns and energy levels to improve rest quality and manage fatigue effectively.

Support and motivation for achieving SMART health goals through regular check-ins and progress tracking.

Regular monitoring of blood pressure readings and related symptoms to prevent complications.

Assessment of social determinants of health and safety concerns to ensure comprehensive care support.

Immediate post-hospital discharge support to ensure safe transition and prevent readmission.