For primary care teams taking risk.
One longitudinal plan per patient, with evidence-based action mapped to each role.
Full Cycle Health is designed to turn clinical guidelines into prompted actions for each team member, the patient and the caregiver, and to keep the plan current as new information arrives.
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Photo: AI stand-in until licensed
One plan that travels with the patient, from the hospital bed to Day 30.
Synthetic patient. Illustrative screens. Screens: illustrative until real captures
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In the bed
Maria Torres, 78 · Heart failure
Admitted- Transitional care nurse Episode opened from the admission notice, with a named owner and a clockDone
- Transitional care nurse Owns the first 30 daysAssigned
- Nurse Bedside medicine review with Maria and her daughter Lisa, one dose mismatch flaggedDone
- Nurse Teach back: what to do if weight goes upPartial, repeat on the first call
- Lisa, caregiver Working scale at homeOpen, confirm by discharge
An admission notice opens one episode with a named owner. Before discharge, the nurse reviews medications at the bedside with Maria and her daughter, Lisa, and records what Maria can explain back.
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Day 0
Maria Torres, 78 · Heart failure
Discharged- Nurse Call Maria within 2 business daysDue
- Physician Resolve the flagged dose mismatchDue
- Pharmacist Confirm the new prescription is filled and how it reaches MariaDue
- Scheduler Book the follow up in the clinic first, video second, and check the rideDue
- Physician and pharmacist Propose a time for each medicine that fits Maria’s dayAssigned
- Lisa, caregiver Weigh Maria each morning and know who to callActive
At discharge the plan is shared. Each person sees the same plan as their own next step, with a due date.
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Day 2
Maria Torres, 78 · Heart failure
Early window- Nurse Reached MariaDone
- Physician Weight up 3.6 lb since her last weight, with mild shortness of breath, reported by Lisa. The nurse has triaged it; the physician decides the water pill dose todayDue today, by 6:00pm
- Pharmacist and physician Maria tells the pharmacist the water pill time collides with her outings and she dreads being caught short on the way to church. The proposal for days she goes out: the water pill moves later in the day, to when she gets home, by 2pmAwaiting physician approval
- Pharmacist New prescription: fill not confirmedOpen, due tomorrow, 12:00pm
- Care team lead Follow up visit not booked, escalatedOpen
Within two business days of discharge, the nurse reaches Maria. A fill that is not confirmed goes to the pharmacist to check access. A step that stalls moves to its next owner.
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Day 30
Maria Torres, 78 · Heart failure
Closure review- Care team Each step has an owner, a time and a recordKept
- Clinician Weight flags reviewed, each decision recordedRecorded
- Pharmacist One medicine list with Maria’s new times, and Maria says it backRecorded
- Care team Clinic visit, home health visit and cardiology video visitDone, documented
- Physician Open itemsNone
- Physician DispositionStable
The episode does not close itself. Closure needs a disposition with a reason and an approver, and the record of who did what, and when, stays with the episode.
Care delivery runs with too much uncertainty.
Leaders and care teams are rarely certain about three things, and each is hard to answer well:
What care is actually delivered.
Guidelines become the next action.
Evidence-based guidelines are designed to become specific actions for each condition, for each team member, the patient and the caregiver, in one longitudinal care plan for each patient.
How well evidence-based standards are followed, patient by patient.
Built so every action has an owner, a deadline and proof.
Each action is designed to carry a named owner, a deadline, an escalation if it stalls, and a record when it is done, to support complete documentation.
How much capacity the team has left to deliver the highest quality care.
Simplify evidence-based execution.
Full Cycle Health is designed to curate data and context from the sources a client connects into one view for each role, so each person can act on the critical path for every patient. It works alongside the EMR and the tools a group already uses.
Following the standard is designed to be something you can see and measure, not something you assume.
For the organization, Full Cycle Health is designed to help make sure the care that guidelines call for gets done, recorded and visible. How much that moves utilization, quality measures and value-based visit documentation is measured with each client against its own baseline.
Two vantage points
Guidelines say what care should happen. Seeing whether it happened, patient by patient, is the hard part.
From running care
Munir Khatri, MD MBA
Co-founder
Helped build the ChenMed operating model, scaled home-based advanced primary care, served as Chief Medical and Chief Population Health Officer of a Medicare and Medicaid provider group, and, as Regional President at CenterWell, carried the full P&L of a multi-state region.
From building the systems
Eric Santiago
Co-founder
A healthcare technology executive who twice served as Chief Technology Officer, owning technology strategy, cybersecurity and data across 200+ care locations.
Two vantage points: running care, and building the systems behind it. Full Cycle Health is designed around both.
Meet the founders Copy lock: Eric approves this summary
Request a walkthrough.
One hour, at no charge. We map your discharge sequence and show where Full Cycle Health fits.
Please do not send patient information.
Or email hello@fullcycle.health