AI-Supported Care Engagement for Next-step Delivery - Medicare Advantage

Inclusion Criteria: •.Enrolled in an eligible Medicare Advantage plan and attributed to Intermountain Health in Utah. * Continuous Medicare Advantage enrollment for at least 6 months before the index date. * PRM Rising-Risk score (an internally derived prediction model) of at least 0.70 and Current-Risk score below 0.95 at index * Predicted year-over-year cost increase of at least 30%. * At least one targeted chronic condition: diabetes mellitus, heart failure, chronic obstructive pulmonary disease, chronic kidney disease, hypertension, or hyperlipidemia. Exclusion Criteria: * Hospice enrollment at index. * End-stage renal disease requiring chronic dialysis at index. * Active oncology treatment at index. * Long-term institutional residence, including skilled-nursing-facility residence, at index. * Primary language cannot be supported through patient-directed outreach and no feasible alternative care-team communication pathway is available.