Figure 1.

(a) Software interface used by providers and care navigators in a sample patient. Highlighted are (i) program targets, (ii) structured inputs needed for treatment recommendations, color-coded by program, (iii) diagnostic questionnaires to capture limited medical history relevant to treatment recommendations, (iv) patient conditions that impact medication choice for the included programs—these are output by the software based on diagnostic questionnaire responses, (iv) automatically determined ICD10 codes and hierarchical coding category scores used to define patient complexity in many value-based care contracts. (b) Sample titration schedules for medication are defined by frequency, starting and ending dose, and days between dose changes. The software-recommended schedule, based partly on meeting the indicated criteria, is indicated by a green check mark. Providers may choose an alternate schedule. (c) Patient journey indicates stage transition dates, treatment choices, and program medications at each stage. (d) Schematic showing patient enrollment by the Community Health Worker (CHW), remote software-enabled comprehensive blood pressure control by the remote team, and handoff back to the primary care provider.