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A care team of four leans over a printed member list at a morning huddle

Population Intelligence

Know which patients need care next.

Fold pulls EHR, claims, ADT and social data into one ranked list, with the reason for each patient, so your team stops building lists by hand.

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How it works

From a risk signal to the right program.

The same four steps as every Fold workflow. Here the signal is a patient whose risk is rising.

  1. 1Signals in
    Claims · OctTwo ED visits in six months
    ADT feed · MonDischarged from St. Mary’s
    Pharmacy · OctMissed a refill
    SDOH · On fileLives alone
  2. 2One patient context
    MEMargaret Ellison, 74Medicare Advantage · heart failure
    Not in a care program yetDaughter Claire helps2 ED visitsMissed refill
    Rising riskEligible for CCM and TCM
  3. 3Next best action
    Enroll Margaret in care management this week
    AI agent ranked her on today’s list, with reasons
    AI agent checked program eligibility
    AI agent added her to Jordan’s queue
    On Jordan’s list · Tue
    JRJordan Reyes, RNOwner · makes the call
  4. 4Owner signs off, result tracked
    Enrolled in CCM
    Care plan started
    First call done
    Tracked in her cohort
    Why she was chosen, kept with the decision

Fold keeps the list current.
Your team works it.

When a hospital discharge, lab or visit arrives, Fold moves the patient to the spot your priority rules set and shows why.

Your priority rules
Set by Emily Carter, quality lead
  1. 1Hospital discharge, 7 daysADT
  2. 2ER visit, 14 daysADT
  3. 3Abnormal labLab feed
  4. 4Social needHRSN screen

4 more rules below these. A saved edit re-ranks the live list.

Each team gets its own worklist.

Quality, risk adjustment, scheduling and care management each get their own list, built from the data you connect.

Every task goes to the right person.

Fold checks availability, workload and patient fit. AI agents handle routine booking. Tasks with no match go to Denise Walker, the supervisor.

See where your panel
needs attention.

Each tier opens as a live worklist with an owner. Margaret is high complexity under Clinical and an open HCC suspect under Risk adjustment, owned by Angela Brooks, CRC.

16xmore screening and diagnosis cases on Fold worklists in 2026 than in 2025. Each case has its reason and an owner.Source: Fold platform data, all customers, 2025 vs 2026.

A practice leader walks an employer client through a printed report at a meeting table

Customer story · Membership primary care practices

One report for every employer.

What changed
Each employer has one report with its own login, and care by text, chat and phone is counted.
Who checks
The practice decides what each employer sees.
Read the story

Set priority rules without SQL. Keep your BI tool.

Do we need SQL to set priority rules?

No. Your care management and quality leads set them in Fold. Leaders you name approve the rules and groups that start outreach.

Can Fold build patient groups from more than EHR data?

Yes. Groups can use EHR data, claims, ADT, labs and pharmacy fills, plus social needs screens, engagement history, attribution and contract terms.

Does this replace our BI tool?

No. Keep your BI tool and its reports. Fold can also work from those reports: it takes you from a measure to the patients behind it and turns the follow-up into assigned work, each step with an owner. Its APIs connect your own apps.

Name one measure.
Leave with its first worklist.

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