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Jordan Reyes, a transitions of care nurse, on the phone at her desk, following a printed medication list with her pen

Care Management

The command center for your care team.

Fold joins EHR, hospital and HIE data into one view of each patient. Your whole care team sees who needs them today and works from one care plan.

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How it works

From a discharge alert to a nurse on the phone.

The same four steps as every Fold workflow. Here the signal is a hospital discharge.

  1. 1Signals in
    ADT feed · Mon 4:02 PMDischarged from St. Mary’s
    Pharmacy · MonFurosemide started, lisinopril stopped
    EHR · MonHeart failure, follow-up due in 7 days
    Claims · 8 moED visit in March
  2. 2One patient context
    MEMargaret Ellison, 74Medicare Advantage · heart failure
    Lives aloneDaughter Claire helps5 medication changesHard of hearing, left
    High readmission riskTCM contact due in 2 business days
  3. 3Next best action
    Call Margaret Tuesday and reconcile her medicines
    AI agent compared her medicine lists
    AI agent flagged the two changes to review
    AI agent booked the call for Tuesday at 9:20 AM
    Ready for Jordan · Mon 5:40 PM
    JRJordan Reyes, RNOwner · makes the call
  4. 4Owner signs off, result tracked
    Jordan reached her Tuesday
    Medicines reconciled
    TCM contact logged
    Visit with Dr. R. Hayes Thursday
    Every step recorded: who did it, and when

Programs and pathways

Programs set the rules. Pathways set the work.

CMS care programs define services and documentation. Care pathways define tasks, timing and owners. Fold brings both into your care team's daily work.

See who needs attention most, and why.

Fold orders each care manager's list and shows the reason beside every name. Open a patient to see an AI summary and the next best action.

Your whole team works from one care plan.

Goals, barriers, assessments and interventions sit in one plan, each with an owner and a due date. A named nurse approves plan changes. A named physician decides treatment.

Reach patients, caregivers and your team from one thread.

Keep patient and authorized caregiver conversations alongside care team notes in one thread, by call, text or app.

Build care pathways around your team.

A care pathway sets tasks, timing and owners. Configure steps in Fold, test changes, and a named clinical lead approves them before use.

  • CMS steps are locked. Fold keeps them in line with program rules.
  • Your steps are yours. Change timers, owners and order.

Manage CMS care programs in one place.

Enrollment, care plans, documentation and billing checks for CCM, APCM and TCM. A named clinician attests before claims are submitted.

5xmore monthly CCM work, tracked to the minute with the care plan. Every chronic care management case keeps its minutes, care plan and next step in one place.Source: Fold platform data, all customers, 2025 vs 2026.

OctoberProgram month

  • Consent before servicesCCM, APCM, BHI, RPM
  • Required documentationEach program
  • Programs billed togetherSame month
  1. GTGrace TurnerCCM20 min staff time

    Claim ready

  2. RMRuth MillerAPCMNot time based

    Conflict

    Held for your coder. Dr. R. Hayes already billed CCM for Ruth in October, and APCM can't be billed with it by the same practitioner that month.

  3. LRLuis RamirezBHI20 min staff time

    Claim ready

  4. DSDorothy ShawTCMContact, medication review and visit on file

    Claim ready

    View evidence
    • Interactive contact within 2 business daysJordan Reyes, RN
    • Medication reconciliation by the visitDr. R. Hayes
    • Face-to-face visit within 14 days (99495) or 7 days (99496)Dr. R. Hayes, signed note
    • 99495 or 99496, from the signed noteYour coder confirms
    • Audit trail and evidence packetKept with the claim
RH

Attested by Dr. R. HayesSupporting diagnoses on each claim

3 ready1 conflict held

Turn missing follow‑up into assigned work.

Track enrollment, care plans and missing visits. Open a measure to see the patients behind it and assign follow-up to a named person.

Population intelligence
A medical assistant calls a patient from the nurse station

Customer story · A multi-site medical group

Every program month in one view.

What changed
Results arrive sorted. Each patient’s program month sits in one view.
Who checks
A coordinator handles exceptions; a named reviewer attests before any claim.
Read the story

AI agents prepare. A named clinician decides.

Licensed staff make every clinical decision, and each completed step links to the record behind it.

Does Fold replace our EHR?

No. Fold connects to 20+ EHRs and hospital and HIE ADT feeds, and writes back where your setup allows. The chart stays the record. We test each connection before launch.

Do we need IT to change a care pathway?

No. Your clinical lead changes timers, owners and step order in Fold, while CMS steps stay locked. Fold tests the draft on past cases, and it goes live only after a named clinical lead approves it.

How does Fold decide who our care managers call first?

Fold orders each care manager’s list and shows the reason beside every name. Your care management leads set the priority rules. Open any patient to see an AI summary and the next best action.

Case study

See it in a case study.

Primary care

How a primary care group automated APCM billing

A new Medicare program, a monthly billing run, and a care team that wanted no extra paperwork.Get the case study

See how your care team
would run on Fold.

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