Case Study: Largest Academic Medical Health Center achieves scaled chronic care improvement with Persistent Systems

World-renowned Academic Medical Center launches next-generation chronic care model

Persistent Systems partnered with the Largest Academic Medical Health Center, a world-renowned academic health system, to address growing volumes of chronic disease patients and the need to improve adherence to best-practice care plans and value-based goals. The health center wanted a more scalable, software-guided approach for care navigators, with access to clinical data and support for remote management of cardiology patients.

Persistent Systems implemented a care navigator-led remote care clinic using digital clinical care, data platform integration, and AI/ML capabilities to identify eligible patients, enroll them into programs, and support proactive outreach for lab and medication adjustments. The solution helped support 5,000+ patients and enabled 80%+ of patients to achieve cardio goals, improving chronic care delivery at scale.