Care coordination has always been one of the most important, yet consistently fragile, aspects of primary care. Even in well-resourced health systems, essential steps like annual visits, preventive screenings, and pre-visit preparation often depend on a patchwork of manual outreach, disconnected reminders, and last-minute scrambles that rarely produce the experience patients or clinicians deserve. Tom’s care coordination services are designed to change that. By connecting routine visit scheduling, annual wellness visit outreach, and pre-visit preparation into a single, proactive flow, Tom ensures that patients arrive more prepared, care teams know what to expect, and essential preventive care doesn’t slip through the cracks.
The Role of Care Coordination Today
For most patients, care coordination has historically meant a short text, a patient portal reminder, or a rushed phone call that does little more than confirm an appointment. It rarely brings meaningful information back into the clinical workflow. Tom reframes the process entirely. When a patient is due for their routine annual or Medicare Wellness Visit, Tom helps ensure the visit is completed by identifying those who are overdue to see their primary care physician and guiding them back into the schedule before they fall out of panel attribution.
As the appointment approaches, Tom initiates a pre-visit conversation that serves multiple purposes at once: it confirms the visit, reduces the risk of no-shows, helps patients articulate their agenda, and provides practical guidance on how to arrive prepared.
Patients lead busy lives, and the details they intend to discuss with their clinician are often only part of everything competing for their attention. Tom’s pre-visit conversation helps surface whatever is on their mind, whether it is one important concern or a long list of questions, and this can meaningfully shape how the visit unfolds. Clinicians typically enter the room with little advanced insight into what a patient hopes to address, and that lack of a shared agenda can lead to disappointment on both sides. By collecting the patient’s priorities before the visit, Tom gives the care team a chance to prepare and set appropriate expectations. The visit begins on firmer ground, not with a surprise list raised as the appointment is wrapping up.
Tom also checks in on medications, ensuring that any issues or confusion around prescriptions are surfaced early.
How This Changes the Experience for Patients and Clinicians
The impact on patients is significant but simple: they feel heard before they even arrive. They know what to expect, they’re reminded to bring what they need, and the care team walks in already aware of what matters to them. Even simple reminders, such as bringing their medications and a list of any questions to their visit, can translate into significantly more effective visits.
Clinicians, meanwhile, gain something invaluable: time that feels better used. When they enter a visit already knowing what’s on the patient’s list, they begin with a clear picture of that individual’s needs. Instead of trying to manage care gaps during a cramped visit, many of those needs can be handled before the appointment even begins.
Health systems also benefit. As more organizations shift toward incentive models that emphasize panel retention and patient continuity, not just RVUs, keeping patients engaged and scheduling on time has become increasingly important. Many systems define a specific timeframe (sometimes 12, 18, or even 36 months) after which a patient is considered inactive and removed from a provider’s panel if they have not been seen. Tom plays a direct role in preventing that attrition. Patients who might otherwise slip away remain connected to their clinicians, and care teams avoid the operational churn of lastminute no-shows or expired outreach windows.
Importantly, all of this creates value without adding new burdens to the care team. For organizations that previously relied on staff to call patients with reminders or gather information, Tom alleviates that workload significantly.
The Technical Approach Behind the Scenes
Tom delivers substantial clinical and patient value, and its technical architecture is intentionally designed to be stable, efficient, and easy to deploy. Tom’s Care Coordination Services are orchestrated through Tom’s Best Next Action Engine, which determines which patients to outreach to when, based on a number of health system inputs and patient factors. Tom conducts a multimodal conversation with the patient over text and voice, integrating patient specific data and health system configurations, and support the patient to take action on their health, be that scheduling the next appointment or educating them ahead of the visit. Tom then processes conversational input, generates an accurate summary, and places it directly into the clinical workflow in a format clinicians can use without delay.
Tom is also designed to work alongside a health system’s existing population health processes. If an organization already uses internal tools to define outreach cohorts, Tom can incorporate those inputs. The guiding principle is flexibility, allowing Tom to fit smoothly within the structures organizations already have in place.
A Look Ahead: What’s Next for Care Coordination
While the capabilities available today already strengthen the connection between patients and their primary care teams, future enhancements will extend that support across more points in the care journey. Tom will gradually expand to help patients routine tasks, like labs, in advance of their visits, giving clinicians more of the information they need when the appointment begins. Additional forms of follow-up after visits and care transitions are also planned, broadening Tom’s role across more of the patient experience.
Why This Matters
At its core, Tom strengthens the connection between patients and the clinicians who care for them. By giving primary care teams a clear picture of each patient before the visit even begins, it shifts the entire appointment toward what matters: understanding the person in front of you and making smart, timely decisions. That shift creates real value. Fewer things slip through the cracks. Preventive care gets completed more often. Clinicians spend less time digging for information and more time using it. The visit becomes a place where patients feel heard and clinicians can do their best work instead of fighting the clock or the chart.
Ultimately, Tom helps clinicians practice the way they always intended, with more clarity, more context, and more meaningful moments with their patients. It also helps patients receive care that feels organized around them, delivered by a team that is ready from the moment they walk in. That’s the value: better care, fewer obstacles, and a visit that works for everyone.
