Agent 02 · Care Agent
Let Ziva handle
the follow-through.
A lot of healthcare work is calling, reminding, checking, collecting information and finding out whether something actually happened. The Care Agent takes on that routine follow-up until the task is done or a person needs to step in.
Transition follow-up · Maria L.*
Owned by Care Agent · day 3 of 30
Day 1
✓ Checked in · feeling okay · discharge instructions understood
Day 1
! New medication not picked up: pharmacy needs prior auth → sent to coordinator
Day 2
✓ Approval in · reminded Maria to pick up today
Day 3
✓ Medication started · ✓ Follow-up visit confirmed for Friday
Next
Day 7 symptom check-in, scheduled per clinic protocol
Staff involved once, for the prior auth. Every step logged to the record.
What the Care Agent does
Something needs to happen for a patient.
Ziva makes sure it does.
The Care Agent isn't an appointment reminder bot. It takes ownership of a follow-up workflow from start to finish, using the same seven steps every time.
01
Contact
Reaches the patient by text or in the app, with voice calls coming soon
02
Ask
The questions your protocol sets
03
Collect
Answers, readings, symptoms, documents
04
Remind
When something hasn't happened yet
05
Follow
Comes back on schedule until it's done
06
Document
Every attempt and outcome recorded
07
Escalate
Brings in the right person with context
Ownership
Ziva owns the task until
one of two things happens.
Staff shouldn't have to remember to chase a patient. Once a task is assigned to the Care Agent, it stays with Ziva and doesn't sit on a nurse's list.
When a patient reports something, the Care Agent sends it to Continuous Intelligence. If it's routine, the workflow continues. If it might be a problem, it's marked Needs Review. A serious concern is marked High Priority and goes straight to a person.
TriggerSomething needs to happenDischarge, new prescription, referral, missing reading, care plan task
→
A · Task completedClosed and documented. Nobody had to make a call.
B · Human judgment neededThe right care team member is brought in with the full history and a suggested next step.
How Ziva reaches patients
Isabella speaks for your care team.
The Care Agent contacts patients through Isabella, on behalf of your organization and following your approved questions.
Live
Text messages
Check-ins, questions and reminders by text, with replies collected and evaluated.
Live
In-app messaging
Conversations with Isabella in the Ziva patient app, with memory of the patient's history.
Coming soon
Voice calls
Isabella calls patients to run the same structured check-ins by phone.
Key use case · Transitions of care
Don't make staff do every routine call.
Bring them the exceptions.
When a hospital, health system or SNF discharges one of your patients, the Care Agent starts your organization's transition workflow. Your team decides which days to check in and what to ask. Ziva doesn't impose a clinical schedule of its own.
Example protocol · set by your organization Configurable protocols · coming soon
Day 1
Check-in
Feeling, meds, instructions
Day 3
Meds
Obtained? Taking?
Day 7
Symptoms
Follow-up booked?
Day 14
Visit
Attended?
Day 30
Hand off
Into ongoing care, not closed
If the patient doesn't respond
Ziva follows your outreach protocol: it retries through another channel, tries again at another time, and escalates to staff after the number of attempts you set.
✦
Isabella · on behalf of Riverside Cardiology
Day 1 check-in · Maria L.*
Hi Maria, this is Isabella, checking in for your care team. How have you been feeling since coming home?
A bit tired but okay.
Glad to hear it. Were you able to pick up your new medications?
Not the new one. The pharmacy said it needs approval.
Continuous IntelligenceNew heart failure medication not started after discharge → Needs review
Thanks for letting me know. I've passed this to your care coordinator so they can sort out the approval. Do you have your follow-up appointment yet?
Sent to care coordinatorMaria L. · prior authorization needed for new medication. Patient otherwise stable, instructions understood. Suggested: contact pharmacy / submit PA today.
Day 2 · approval in
Good news, Maria. Your new medication is approved and ready at the pharmacy. Can you pick it up today?
Yes, my daughter is getting it this afternoon.
Day 3
Just checking: were you able to start the new medication?
Yes, took it this morning.
Record updatedBarrier · coordinator action · approval · pickup · started. Next: day 7 symptom check-in.
*Stories are inspired by real patient experiences and health patterns observed in care. Names, images, quotes, and certain details have been changed or combined to protect privacy. Individual experiences and outcomes may vary.
Beyond day 30
Day 30 isn’t the finish line.
The Care Agent keeps going.
A transition ends, but the condition doesn’t. When the 30-day window closes, the patient moves into ongoing care, and the same agent keeps following up for as long as they’re enrolled. There’s no end date and no handoff back to a staff to-do list.
Day 0–30 · TransitionIntensive, protocol-drivenCheck-ins on your schedule, medications, follow-up visit, documents.
Month 2 onward · Ongoing care, no end dateSteady, and it steps up when something changesMonthly check-ins, missing readings, refills, referrals, care plan tasks. When something changes, it moves into observation or escalation, then settles back.
Monthly check-inMissing readingsRefillsReferralsCare plan tasksNew transition if readmitted
Every follow-up ends in an action
01 · Follow up
Checks back with the patientComes back on schedule until there’s an answer, and retries on another channel if needed.Text & app · live02 · Update
Writes it to the recordEvery attempt, answer and outcome is documented, so the next person starts with the full story.03 · Message
Tells the providerSends a short, ready-to-act note: what happened, what changed and a suggested next step.04 · Observe
Watches before reactingIn Clinical Observation Mode, it checks in and collects readings to see whether things improve.Observation · live05 · Alert
Escalates when it mattersContinuous Intelligence raises a priority alert to the right person, with context.Priority states · coming soonScenarios · months after discharge
How the Care Agent handles
the months that follow.
Four common situations. In each one the agents do the routine work and people come in only when their judgment is needed.
Month 4 · illustrative
James R.*, 61 · HypertensionBlood pressure drifts up. The provider chooses to watch instead of changing medication.Mon
IntelligenceShift from baseline
7-day systolic average is 152 against James’s personal baseline of 134. Below the clinic’s critical line, but a real change.
Needs review Sent to Dr. Patel’s inbox with the trend and last 3 check-ins.
Mon
PersonProvider chooses observation
Dr. Patel opens it, sees James mentioned travel and missed doses, and starts Clinical Observation Mode for 5 days instead of adjusting medication.
Tue–Fri
Care AgentOne check-in, then reminders only if needed
Isabella asks James once how he’s feeling and whether he’s back on his medication. Readings come in from his cuff. When Thursday’s reading is missing, Isabella sends one reminder.
“Feeling fine, back home and back on routine.” · Thu: “Forgot this morning, taking it now.”
Sat
IntelligenceRe-evaluated: improving
Average back to 138 and trending to baseline. Observation closes as resolved.
Sat
Care AgentRecord updated, provider informed
The observation summary is written to James’s record and Dr. Patel gets an FYI. James returns to routine monthly check-ins.
What Ziva did on its own
Followed up with the patient
Updated the patient record
Messaged the provider
Ran Clinical Observation Mode
Raised a priority alert
1Staff touches
6Days Ziva owned it
Outcome: no extra visit and no phone calls. The provider spent one two-minute review.
Month 7 · illustrative
Dolores M.*, 74 · Heart failureObservation shows things getting worse. Intelligence escalates before the next visit would have.Day 1
IntelligenceEarly signal
Weight up 1.2 kg in 3 days. Dolores reports mild ankle swelling in her check-in.
Needs review Nurse sets 3-day observation on her connected scale readings.
Day 2
Care AgentOne check-in on how she’s feeling
Isabella asks once about breathing, swelling and medication. Weights keep arriving from her scale, so no daily texts are needed.
“A bit more out of breath on the stairs today.”
Day 3
IntelligenceEscalated: High Priority
Weight now up 2.4 kg with new shortness of breath. Observation stops and an alert goes to the on-duty nurse.
High priority Weight trend, medication list, last 3 check-ins and a suggested next step, all in one view.
Day 3
PersonNurse calls, provider adjusts plan
The nurse reaches Dolores the same afternoon. The provider changes her diuretic dose.
Day 4–10
Care AgentFollows the new plan
Confirms the dose change and asks how she’s feeling after it. Watches her scale readings and reminds her only if one is missed, until she’s back to her usual weight. Every step goes into her record.
What Ziva did on its own
Followed up with the patient
Updated the patient record
Messaged the provider
Ran Clinical Observation Mode
Raised a priority alert
2Staff touches
10Days Ziva owned it
Outcome: worsening was caught on day 3 with full context, not found at the next visit. People were involved only where their judgment was needed.
Month 10 · illustrative
Ahmed K.*, 58 · Type 2 diabetesA routine monthly check-in finds a gap. The provider just has to sign.Day 1
Care AgentMonthly check-in
Isabella asks the usual questions, including about medications.
“Ran out of metformin last week. Pharmacy says the prescription expired.”
Day 1
IntelligenceFlagged as a medication gap
Six days without a maintenance medication. Routine, but needs action.
Needs review
Day 1
Care AgentProvider messaged with a ready request
A renewal request goes to the provider with the last fill date, recent glucose readings and the pharmacy on file.
Day 1
PersonProvider signs
One signature. No phone tag between front desk, pharmacy and patient.
Day 3
Care AgentPickup confirmed, record updated
Ahmed confirms he picked it up and restarted. The gap is closed in his record and noted for the next visit.
What Ziva did on its own
Followed up with the patient
Updated the patient record
Messaged the provider
Ran Clinical Observation Mode
Raised a priority alert
1Staff touches
3Days Ziva owned it
Outcome: the gap was found at month 10 because the agent was still checking in. It didn’t wait for the quarterly visit.
Month 14 · illustrative
Linda P.*, 69 · COPDNo replies and no readings. Ziva doesn’t give up, and it doesn’t keep it to itself.Day 1
Care AgentMonthly check-in unanswered
Isabella retries at a different time of day, then by in-app message, following the clinic’s outreach protocol.
Day 5
IntelligenceSilence noticed
No reply after 3 attempts, and no oximeter readings for 9 days, which is unusual for Linda.
Needs review
Day 5
PersonCare manager reaches out
A task with last contact, recent trend and emergency contact. The care manager calls and learns Linda was admitted to another hospital.
Day 6
Care AgentDocuments requested
The Care Agent requests the discharge summary, reads it when it arrives, and summarizes what changed.
Day 8
Care AgentNew transition starts
Linda is home, and a new 30-day transition starts on top of her ongoing care. The cycle continues.
What Ziva did on its own
Followed up with the patient
Updated the patient record
Messaged the provider
Ran Clinical Observation Mode
Raised a priority alert
1Staff touches
8Days Ziva owned it
Outcome: an outside admission that might have gone unnoticed until her next visit turned into a structured transition within days.
*Stories are inspired by real patient experiences and health patterns observed in care. Names, images, quotes, and certain details have been changed or combined to protect privacy. Individual experiences and outcomes may vary. Escalation timing and check-in questions follow your organization’s protocols.
Built to scale
Staff time grows with exceptions,
not with the number of patients.
Following up with every patient every month is impossible to do by hand. With Ziva, adding patients adds agent work. Your team’s workload only grows when there are more exceptions.
Care Agent · every patient
Every patient, every cycleCheck-ins, readings, refills, referrals and observation follow-ups, run on your protocols.Intelligence · what changed
Every response is evaluatedEach answer and reading is compared with the patient’s own baseline. Routine results stay quiet.Your team · what needs a person
Only the exceptionsReviews, decisions and calls, each one arriving with the history and a suggested next step.No end date
Follow-up runs for as long as the patient is enrolled.
Your protocols
Your team sets the questions, timing and escalation rules.
Always documented
Every touch is recorded, ready for review and reporting.
Restarts itself
A new admission starts a new transition automatically.
Documents inside the workflow Reading & summarizing · live
Documents give the agents context.
They aren't the product.
During a transition, Ziva can check whether the information the care team needs is actually there. It reads and summarizes what it finds and flags what's missing. Ziva isn't a document management system. Documents are context for the Care Agent and Continuous Intelligence.
01
Verify
Is it here?
02
Read
Extract what matters
03
Summarize
Short, clinician-ready
04
Route
To the right person
05
Flag missing
Request what isn't there
✓ ReceivedDischarge summarySummarized for the care team
✓ ReceivedMedication listChanges vs. pre-admission noted
✓ ReceivedFollow-up instructionsUsed in check-in questions
✓ ReceivedOrdersLabs to schedule identified
! MissingReferral informationFlagged to coordinator
One agent, many workflows
The same Care Agent,
applied to every kind of follow-up.
There isn't a separate branded agent for each task. Each workflow runs your protocol through the same loop of contact, ask, collect, remind, follow, document and escalate.
Workflow
Transitions of care
Discharge → check-ins → meds, follow-up, symptoms → exceptions escalated
Explore →
Workflow
Medication follow-up
Prescribed → obtained? → started? → barrier identified
Explore →
Workflow
Referral follow-through
Ordered → scheduled → attended → specialist info → loop closed
Explore →
Workflow
Clinical observation
"Observe 3 days" → repeat readings → re-evaluate → continue or escalate
Explore →
Workflow
Post-discharge check-ins
Hospital, ED or SNF transition → protocol check-ins → escalate concerns
Explore →
Workflow
Missing measurements
Required reading missing → request → remind → collect → evaluate
Explore →
Workflow
Care plan follow-up
Care team asks → Ziva follows up → completed or exception
Explore →
Workflow
Patient surveys & check-ins
Structured questions → responses collected → evaluated → routed
Explore →
Take the routine calls
off your team's list.
Show us one follow-up workflow your staff run today, and we'll show you how the Care Agent would handle it.