Multimorbidity Management
Better Outcomes, Lower Utilization
Proven to reduce utilization, improve self-management, and reduce burden on your care team
Florence, the AI Nurse, automates routine care of complex patients with multiple chronic conditions. Through frequent, human-like interactions, she engages, manages, and monitors your patients; and only notifies her human colleagues when appropriate.
65-75% reduction in hospital utilization
97% say ‘easy to use’; personalized in English, Spanish
Evidence-based protocols & safe AI drive self-management
Medication adherence, symptoms tracking & SDOH risks
Strong ROI: Increase team productivity 5-10x
Clinical Validation: Better Outcomes & Reduced Utilization
| Diabetes & Hypertension: | COPD (with HTN/DM): | CHF (with HTN/other): |
| ↓1-point A1c |
↓70% Emergency admissions |
↓66-70%, Emergency readmissions |
| ↓15% Systolic BP |
↓81% Less PCP |
↓40-45% All-cause readmissions |
| ↑113% Med adherence |
54% Care managers report more appropriate patient encounters |
|
| ↓63% Clinical time (multiple studies) |
Why so Effective? Whole Person, Simple, Self-Management
Whole Person Care: Managing patients with comorbidities requires a multi-dimensional approach; Florence does not manage a condition in isolation but combines vitals, medication adherence, symptoms management with life-style modifications, identification of SDoH risks and patient well-being.
Simple: High-risk comorbid patients often live harder, more challenging lives, have lower levels of literacy, often in shift work and have access to fewer resources. But a vast majority have a cell phone and Florence is simple – no app to download, no internet required. She is fluent in English and Spanish (as standard) and can be configured to other languages.
Self-management: Florence’s priority is to empower and drive patients to better self-management – recognized as key to delivering better outcomes and reducing utilization of polychronics. She is empathetic and knowledgeable. She provides immediate feedback and non-judgmental responses in the patient’s preferred language. Florence will nudge and educate with frequent bitesize messages around topics like smoking cessation or avoiding salty food and can answer questions.
94% of patients said that Florence helped them to manage their own health (COPD)
89% of patients improved their understanding of their heart failure (CHF)
67% of patients were motivated to improve their overall health (CHF)
“I’ve been motivated to walk. I’ve lost 7kg in weight and we’ve reduced a couple of tablets from 20mg to 5mg and heart medication from 2 tablets to 1. I felt Florence was a friend and she was trying to help me.”
Stuart, HNHC patient with diabetes, heart failure
Quick Configuration with Protocol Library
We have a library of evidence-based protocols that can be optimized to your patient cohort and care setting within weeks.
Objective
Support patients from diagnosis through long-term management by tracking blood pressure and glucose, improving medication adherence, supporting lifestyle changes, and addressing barriers to control.
Typical Florence Protocol Areas
- Reminders for antihypertensive and diabetes medications
- Tracking BP and BG readings
- Mood check-ins to support mental health and behavior change
- Bite-size education and lifestyle advice
- SDOH risk assessment and support
Objective
Support patients managing hypertension, diabetes, and high cholesterol from diagnosis through long-term control by tracking clinical values, optimizing medication adherence, and addressing lifestyle and social barriers.
Typical Florence Protocol Areas
- Reminders for antihypertensive, diabetes, and lipid-lowering medications
- Guidance on medication timing and tracking of side effects
- Tracking BP, BG, and mood
- Bite-size education and lifestyle advice
- SDOH risk assessment and support
Objective
Support patients with Stage 2–4 CKD by promoting blood pressure and glucose control, improving medication adherence, and encouraging lifestyle changes to help slow disease progression.
Typical Florence Protocol Areas
- Reminders for antihypertensive and other renal-protective medications
- Tracking BP, BG, and mood
- CKD-specific education and lifestyle advice (diet, fluid, NSAID avoidance)
- SDOH risk assessment and support
Objective
Support patients across the spectrum from mild to severe persistent asthma by improving inhaler adherence, tracking symptoms, detecting early warning signs, and reducing preventable exacerbations.
Typical Florence Protocol Areas
- Reminder for controller inhaler
- Support use of SABA/rescue inhaler and tack usage
- Support symptom tracker – Green/Yellow/Red zone
- Bite-size education and lifestyle advice (inc smoking)
- SDOH risks
Objective
Support patients with moderate to severe COPD to reduce exacerbations, improve medication adherence, and maintain symptom stability.
Typical Florence Protocol Areas
- Daily symptom check-ins and early detection of exacerbations (dyspnea, sputum changes, fatigue)
- Reminders for maintenance inhalers (e.g. LAMA, LABA, ICS) and track rescue inhaler use
- Support Green/Yellow/Red zone self-management plan
- Bite-size education on breathing techniques, inhaler use, oxygen therapy, and pacing activities
- Support for smoking cessation with motivational messages and resource links
- Assess and address SDOH risks (e.g. housing, transportation, access to other care)
Objective
Support patients with chronic heart failure by improving medication adherence, tracking daily symptoms and weight, detecting early signs of fluid overload, and reducing avoidable hospitalizations.
Typical Florence Protocol Areas
- Medication reminders for diuretics, beta blockers, ACE/ARBs, etc.
- Daily weight tracking to monitor fluid retention
- Symptom tracker – Green/Yellow/Red zone for shortness of breath, swelling, fatigue
- Bite-size education on sodium restriction, fluid limits, activity, and self-care
- SDOH risk assessment (e.g. food access, housing, transportation)
- Assess and address SDOH risks (e.g. housing, transportation, access to other care)
How Does it Work?
Imagine a trusted nurse having frequent conversations via text with your patients to pro-actively manage and support them after their hospital discharge. Florence follows agreed protocols and is human-like in her understanding of patients; she takes on all routine work and can notify her human colleagues when required.
