Your patients need more care between visits. Now there's a reimbursed system to deliver it.
Populate helps specialty practices deliver chronic care management and behavioral screening between visits - with automated outreach, structured documentation, and billing-ready workflows.
How it works
Two automated programs that run in parallel.
Chronic Care Management (CCM) Program
Monthly patient engagement
Psych Screening Program
Behavioral assessment
What these programs actually do
Chronic Care Management (CCM)
A reimbursable program for patients with two or more chronic conditions. It supports monthly non-face-to-face care between visits, including check-ins, care plan updates, medication follow-up, and coordination.
Psychological Screening
Structured behavioral assessments delivered between visits to identify depression, anxiety, and other risk factors that affect recovery, adherence, and surgical outcomes. Screening instruments include PHQ-9, GAD-7, SSS-8, NIDA-Modified ASSIST, ASRS, MDQ, and Columbia Suicide Severity Rating Scale.
What each role sees
The right summary for each person
Same signal. Different lens. Less noise between visits.
CARE TEAM
Knows what changed
Structured routing with clear ownership. Every finding reaches the right person with a specific next step — before it becomes a problem.
PHYSICIAN
Knows what matters
A synthesized clinical brief before every visit. What changed, what was escalated, what the team handled. Walk in prepared, not catching up.
PATIENT
Knows what to do next
Monthly check-ins provide support, medication guidance, and clarity across the 8,756 hours between clinical visits. Patients aren't alone between appointments.
The gap
Providers want to give more care.The system hasn't made it sustainable.
“The U.S. healthcare system continues to emphasize acute and episodic interventions over the proactive, holistic approach fundamental to effective longitudinal care.”
PMC — Healthcare Continuity in Crisis, 2025
The biggest disconnect in healthcare isn't clinical knowledge — it's operational infrastructure. Providers know what their chronic patients need between visits. What's missing is a practical, reimbursed system to deliver it. Continuous Care is that system.
125K
deaths per year from medication non-adherence in the U.S.
source: Kleinsinger F. The Unmet Challenge of Medication Nonadherence. The Permanente Journal, 2018. PMID: 30005722. DOI: 10.7812/TPP/18-033.
50%
of chronic disease patients don't take medications as prescribed globally
WHO / Frontiers in Pharmacology, 2024
8,756
hours per year patients manage chronic conditions without clinical support
Derived estimate: 8,760 annual hours minus ~4 hours average physician contact (Tai-Seale M, et al. - Health Affairs, 2017).
What happens when the gap closes
Patients with chronic conditions spend fewer than 4 hours per year with a clinician. Continuous Care supports the other 8,756.
Without between-visit support
- Medication lapses go undetected until the next visit
- Symptom changes escalate without early intervention
- Missed referrals and follow-ups fall through the gap
- Patients feel unsupported and disengage from care plans
- Minor problems compound into expensive emergencies
With Continuous Care
- Monthly check-ins detect changes before they escalate
- Patients have a consistent care presence between visits
- Care gaps are identified and routed to the right person
- Patients receive guidance, education, and next steps
- The physician walks in already knowing what changed
30%–50%
30%–50% of MSK patients are non-adherent to home exercise and rehabilitation programs.
source: Jimenez-Garcia JA, et al. JMIR mHealth and uHealth, 2018.
77%
Of patients in digital Chronic Care Management (CCM) studies reported improved health and self-management ability
PMC Systematic Scoping Review, 2025 - 69 platforms, 20 chronic diseases
8%–62%
Non-adherence to analgesic medication affects 8%–62% of chronic pain patients, weighted mean 40% across 25 studies.
source: Timmerman L, et al. Acta Anaesthesiologica Scandinavica, 2016. PMID: 26860919.
Revenue from patients you already serve
Recurring reimbursement without adding staff.
Chronic Care Management
Monthly outreach
Psych Screening
Structured assessments
Estimated monthly revenue
$17,060
From patients you
already serve
4 fewer
hospitalizations
22 more
patients with improved adherence
Revenue and clinical projections are illustrative estimates based on modeled assumptions and published population-level evidence. Actual financial and clinical results will vary by patient population, payer mix, enrollment, workflow adoption, and clinical follow-through. Populate does not guarantee reimbursement, utilization reduction, or clinical outcomes.
Why practices choose it
Continuous Care is built for the realities of running a specialty practice.
New recurring revenue
Chronic Care Management (CCM) and psych screening create monthly reimbursement from your existing patient panel.
No new hires needed
AI handles outreach and documentation. Your staff reviews and approves.
Minimal staff time
Automated workflows reduce the hours typically required for CCM compliance.
Better between-visit visibility
Capture status changes, adherence signals, and symptoms between appointments.
Billing-ready documentation
Notes and time tracking are generated automatically for compliant reimbursement.
See the clinical research behind Continuous Care