← Mockups | Caliber ops · Care-team console
Risk stratification + outreach engine

Risk cockpit

312 attributed members · Devoted MA contract · updated 8 min ago
Deteriorating
23
+4 since yesterday
Rising risk
41
watch list
Stable high-risk
118
routine touch cadence
Improving
87
last 30d
Unreachable
12
3+ failed contacts
Prioritized work queue
value × time-sensitivity
  • Hawkins, Robert L.Tier 1
    71 · M · Schizoaffective, CHF, T2DM
    New persecutory content + sleep loss · pattern matches '24 admission
    Next action
    Call today
  • Delacroix, MireilleTier 1
    68 · F · MDD recurrent, T2DM
    PHQ-9 6→11 · missed 2 SMS · pharmacy gap 5d
    Next action
    Call today
  • Okonkwo, SamuelTier 2
    74 · M · Bipolar I, COPD
    Sleep dropping, possible mood elevation signals
    Next action
    Call this wk
  • Park, Yong-HeeTier 2
    69 · F · GAD, HTN
    New caregiver burden signals · husband recent dx
    Next action
    Outreach
  • Alvarez, MarisolTier 2
    72 · F · Schizophrenia, T2DM
    Pharmacy gap 6d · last reached 2 wks ago
    Next action
    Pharmacy
  • Williams, EstherTier 3
    76 · F · SMI NOS, HFpEF
    Routine 30d check-in due
    Next action
    Schedule
  • Brennan, PatrickUnreachable
    70 · M · MDD, CKD stg 3
    3 missed calls · last reached 18 days ago
    Next action
    Home visit?

Robert L. Hawkins

Tier 1 · Deteriorating
71 · M · Devoted MA · MRN 8842310 · attributed 14 mo
Last reached 3 days ago · Best contact time 10am–noon · Prefers voice

Why Robert is at the top of your queue today

caliber-priority-v2 · expected admission averted: $14.2k
●
High clinical signal
Pattern matches 14-day pre-admission window from '24
●
Time-sensitive
Historical lead time → admission is ~21 days
●
High intervention success
Robert has 4/5 prior outreach attempts answered
●
Trust with you
You've been his CM for 11 mo · rapport score 0.86

Suggested outreach script

Personalized to Robert's history and current signals
Open
"Hi Robert, it's Janelle from Caliber. I saw your check-in came through this morning and wanted to call. How's the sleep been since we last talked about the neighbors?"
Probe
"You mentioned hearing them talking about you — is that still happening every night, or just some nights? When did that start?"
Goal: determine if persecutory content is escalating frequency vs. content
Adherence
"Want to make sure I've got this right — you picked up the clozapine last Tuesday, right? Any side effects we should mention to Dr. Reyes?"
Robert had a 4-day gap; don't assume non-adherence — verify
Plan
"I'd like to get you in to see Dr. Reyes this week instead of waiting til the 12th. Can I look at her schedule with you now?"
📋 Disposition will auto-log after the call
Recent touchpoints
  • 05/19You · outreach call, 12 min · agreed to PCP visit
  • 05/16SMS · weekly check-in completed
  • 05/14Dr. Reyes · psych f/u
  • 05/10Pharmacy alert · 4-day clozapine gap
  • 04/28PCP · BP check
Care plan · open items
  • Confirm pharmacy delivery setup (was self-pickup)
  • Schedule psych f/u within 7 days
  • Home scale calibration check
  • Re-enroll in weekly SMS
  • Loop in daughter (HIPAA auth on file)

Your cohort impact · last 90 days

vs. matched control panel
−38%
Psych inpatient admits
−24%
ED visits
87%
Measurement completion
$412k
Est. shared savings