Boston-based health system launches next generation chronic care model| Persistent Systems

Client Success

World-renowned Academic Medical Center launches next-generation chronic care model

A premier academic health system’s cardiology division takes best practices and AI to scale with a care navigator-led remote care clinic.  


The health system faced increased volume of chronic disease patients and wanted to ensure best practices would be adhered to by providers. Also, they wanted to improve adherence to care plans and value-based goals that require cost reduction through fewer office visits.


One of the nation’s largest and most respected hospitals, internationally acclaimed for excellence in clinical care, wanted to create a platform to provide software-guided decision making for care navigators.

Required capabilities included:

  • Identification of patients with specific clinical characteristics
  • Screening and enrollment of patients into relevant programs
  • Continuous live access to clinical data in the EMR
  • Inform proactive and periodic outreach by care navigators for patients for coaching and treatment guidance related to labs and medication adjustments
  • Support navigator-driven remote care for hypertension, heart failure and lipid control
Impact of the solution delivered by Persistent


Patients supported


Patients Achieved Cared Goals


Persistent delivered a full life-cycle implementation that not only re-imagined internal business processes but also helped the bank leverage cutting edge AI and ML technologies for automation.

  • 92% accuracy on data extraction and decisions using AI/ML cognitive automation
  • Reduced Turn-Around-Times (TAT) from 30-45 minutes to 7-8 minutes
  • Increased operational efficiency by automating human-intensive operations
  • Rapid deployment of five new applications in three months across the trade supply operations
  • Reduced Total Cost of Ownership (TCO) by reusability of existing product licenses
Technologies used
  •  Digital Clinical Care
  •  Data Platform Strategy
  •  Enterprise & Data Integration
  •  Artificial Intelligence & Machine Learning
  •  Identity Access Management

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