What does Comara Care help PCP and integrated-network teams do?

Comara Care helps PCP, clinic, and integrated-network teams close the loop after discharge for their attributed patients, with patient and caregiver engagement, medication reconciliation, follow-up scheduling, referral closure, and evidence capture.

Who is Comara Care built for?

Comara Care is sold to Medicare-heavy PCP practices, hospital-owned primary care networks, rural health clinics, ACO/CIN groups, GUIDE organizations, and care-management leaders who own the downside when a transition fails.

What does Comara Care use AI for?

Comara Care uses AI to extract tasks, dates, medication changes, missing information, red flags, and follow-ups from messy care artifacts, then routes work for human review.

An older woman and her adult daughter reviewing a discharge paper together at a sunlit kitchen table at home

Comara Care

Post-discharge care management

Close post-discharge care gaps, with evidence attached.

We help Medicare-heavy PCP practices, hospital-owned primary care networks, and ACO/CIN teams close the loop after discharge for their attributed patients.

Book a discovery call Send us a message

Provider-sponsored workflows for clinic teams, patients, and caregivers across web, apps, SMS, and voice.

The problem

Discharge is chaotic. And outcomes, revenue, and quality get lost in the shuffle.

After discharge, every stakeholder is dealing with a different version of the same problem: the PCP practice or integrated network carries the financial and quality risk, the clinic care team owns a long list of time-sensitive follow-up work, and patients are trying to navigate one of the most confusing moments in their care journey.

Owning Organizations

Unmanaged transitions create real financial exposure for the organizations that own the patient after discharge. Fee-for-service PCP groups can leave reimbursable work unbilled when outreach, visit timing, medication reconciliation, and documentation are incomplete. ACOs, CINs, GUIDE programs, and other at-risk partners feel the impact through avoidable utilization, readmission risk, quality pressure, and patient experience.

The problem is not one missed call. It is a fragile process where revenue, quality performance, and preventable cost depend on every step happening on time, with evidence.

The product

One post-discharge closure process for attributed patients.

Comara Care is an AI digital assistant and hub for post-discharge follow-through, helping PCP and integrated-network teams coordinate what needs to happen, who owns it, what is still open, what evidence has been collected, and where the next escalation should go.

PCP & Network Teams

PCP, clinic, and integrated-network teams get a daily dashboard for the work that has to happen after discharge: outreach, reminders, medication reconciliation, follow-up scheduling, home health coordination, transportation checks, caregiver communication, and documentation.

Comara Care turns discharge packets, patient responses, caregiver input, and clinic notes into structured tasks with owners, due dates, source links, and escalation paths. The goal is not another inbox. It is a cleaner way to know what needs attention, what is already handled, and what proof exists.

Patients & Caregivers

RRina S.

Home · day 2

Hi Rina, we're just checking up on you now that you're home. Are you ready to schedule your follow up appointment with Dr. Jackson?

Care team · 10:14am

Yes, I'm free tomorrow afternoon

Rina · 10:16am

Great, how is 3pm?

Care team · 10:17am

Patients and caregivers get simple instructions and clear support via web, SMS, app, and voice. Comara Care helps them understand what changed, what appointments are coming up, what medications need attention, what symptoms to watch, and who needs to be looped in.

The experience is designed for a confusing moment: multiple instructions, multiple people, and a lot of stress. Instead of expecting families to interpret discharge paperwork on their own, Comara Care gives them simple prompts, reminders, and ways to report barriers before small gaps become bigger problems.

Network & Practice Admins

Network and practice admins get info on whether post-discharge work is actually happening across clinics, locations, and patient populations. Comara Care gives them a live view of open loops, overdue tasks, escalation patterns, documentation gaps, and evidence status.

Instead of relying on manual audits or scattered reports, admins can see where attributed transitions are breaking down, which workflows need staffing or process changes, and which episodes are ready for review.

How it works

From attributed transition to completed closure.

1 detect

Detect the transition.

An ADT feed, owned-clinic discharge roster, encounter list, patient or caregiver upload, or PCP referral creates an episode with deadlines, missing fields, and the right review path.

2 reach

Reach the right person.

Comara Care verifies patient and caregiver channels, contact preference, relationship, and permission status before outreach scales.

3 structure

Turn instructions into work.

Discharge paperwork, portal screenshots, caregiver notes, and medication photos become structured tasks and review items.

4 escalate

Escalate what stalls.

Failed contact, missing payload, medication discrepancies, transportation barriers, caregiver conflict, and high-risk language route to the approved human owner.

5 close

Produce the closure record.

The episode closes with evidence: what happened, who verified it, what is still open, and what billing, quality, or care-management can review.

The evidence

Close the loop clinically, financially, and defensibly.

Post-discharge follow-up only matters to the owning provider organization when it comes back as timely, source-linked evidence: who was contacted, what happened, what code or quality measure it supports, and what still needs escalation.

~10-15%¹ Typical billed TCM capture remains low across Medicare and provider-population benchmarks.

40-60%² Modeled pilot target once attributed transition triggers, contact, visit timing, medication-reconciliation status, ownership, and evidence capture are managed in one workflow.

Illustrative operating model for pilot planning. Final performance depends on attributed discharge volume, patient mix, staffing, payer rules, and verified baseline TCM capture.

1. Baseline range references a 2015-2019 Medicare FFS analysis reporting TCM in 10.9% of eligible discharges, plus a 2022 provider-population benchmark reporting 15%. Park et al. Pearl Health

2. Pilot target is a Comara internal planning model, not observed performance. Workflow assumptions map to CMS TCM requirements for timely contact, face-to-face visit timing, and medication reconciliation. CMS MLN

Timely reporting back to the owning provider

Every attributed transition should return a daily status: contact attempts, patient response, appointment readiness, medication issues, open barriers, owner, due date, and whether the record is ready for billing, quality, or care-management review.

contact log owner timestamp next escalation

FFS evidence for TCM billing review

For fee-for-service workflows, Comara Care helps assemble the operational evidence needed to review CPT 99495 or 99496: discharge date, qualifying contact within 2 business days, medication reconciliation status, visit timing, complexity signals, and unresolved follow-up work.

99495 · 14-day visit 99496 · 7-day visit 2-business-day contact

At-risk quality closure

For ACOs, CINs, GUIDE programs, and MA-aligned partners, the evidence packet should support transitions-of-care reporting: admission notification, receipt of discharge information, patient engagement after discharge, and medication reconciliation after discharge.

TRC med reconciliation patient engagement discharge info

Compliance-ready closure record

Each episode should preserve source documents, outreach attempts, patient and caregiver permissions, reviewer actions, failed attempts, escalation decisions, and final disposition so teams can explain what happened later.

source-linked audit trail consent scope final disposition

ROI

How much TCM revenue are you leaving unclaimed after discharge?

Use practice-specific discharge volume, eligibility assumptions, payer mix, locality, and staffing model to estimate gross upside and net ROI.

Monthly discharges 120

TCM-eligible share 45%

Captured today 15%

Avg TCM reimbursement $210

Pilot recovery rate 40% Share of today's leakage a focused pilot recovers. 40% is a top-quartile stretch target, not a floor — observed top performers reach roughly 55% total capture.

Payer / risk model

Fee-for-service Value-based / at-risk

Quality and avoided-readmission value accrue to at-risk entities (ACO, CIN, GUIDE, and MA-aligned partners), not fee-for-service billers. Switch to value-based to model them.

Optional ROI add-ons

Quality / Stars value Add estimated quality upside per closure. MedEx readmission avoidance Add modeled medical-expense savings from fewer readmissions. Care team time savings Add estimated staff time recovered per eligible discharge.

Calculator outputs are planning estimates, not reimbursement promises. Billing decisions remain with the provider and billing team. Reimbursement, recovery, quality, MedEx, and staffing assumptions should be replaced with practice-specific, locality-adjusted figures.

How this ROI model is calculated

Annual TCM opportunity = monthly discharges × 12 × TCM-eligible share × average TCM reimbursement.
Estimated annual leakage = annual TCM opportunity × uncaptured share.
Gross annual upside = recoverable TCM leakage plus selected quality, MedEx, and staff-time add-ons.
ROI and net ROI use internal planning assumptions applied to the modeled gross upside.
TCM billing still depends on payer rules, required contact, visit timing, medication reconciliation, documentation, and billing review. See CMS TCM guidance.

Annual TCM opportunity theoretical

$136K

$20K captured today at the selected capture rate; full capture is a ceiling, not a forecast.

Estimated ROI multiple modeled case

4.6x

Estimated net benefit

$36K

Estimated annual leakage

$116K

Gross annual upside selected add-ons

$46K

TCM pilot recovery$46K Additional closed episodes220 Quality / Stars$0 MedEx readmissions$0 Staff time$0 Net benefit$36K Net ROI3.6x

Trust

Built for BAA-governed provider deployments.

Comara Care is designed for HIPAA-aligned workflows with role-based access, audit logs, source-linked outputs, scoped caregiver permissions, and human review where clinical judgment is required.

Role-based accessScoped to what each role needs to see and do.

Audit logsEvery action recorded for review.

Source-linked outputsEvery claim traces back to its artifact.

Scoped caregiver permissionsPermissioned, logged, and revocable.

Human reviewClinical judgment stays with clinicians.

BAA-governedDesigned for HIPAA-aligned provider deployments.

Final step

We'd love to chat on how we can help.

Start with a real attributed transition queue, measured staff time, patient and caregiver activation, medication-review workflow, visit scheduling, open-loop closure, and evidence completeness.

Book a discovery call Send us a message