Process

DiNC reimagines care delivery by shifting the system from isolated visits to continuous, structured care journeys. It aligns services around clinical milestones, replaces passive follow-ups with proactive outreach, and ensures every referral is tracked until completion — enabling better continuity of care, improved patient adherence, and stronger long-term health outcomes.

Why process redesign is the
foundation

In a conventional public health system, care is episodic. Patients come in, are treated, and leave—often without structured follow-up. Referrals are initiated but not consistently tracked. Data is recorded, but rarely used to close the loop on care delivery.

DiNC does not change the facilities or the clinical workforce. Instead, it redesigns the system around them—introducing structured care pathways, milestone-based tracking, proactive follow-ups, and closed-loop referral management. This ensures continuity of care, accountability at every level, and that no patient journey is left incomplete. These processes also help strengthen the implementation and improve the outcomes of government health programs.

Tech

THE FIVE PROCESS SHIFTS

From fragmented to connected

Episodic, one-time facility visits
Patient must return — system is reactive
One-way referrals with no confirmation
Isolated interactions, no shared history
Programme compliance as an aspiration
Milestone-based, longitudinal care journeys
System initiates contact at every milestone
Closed-loop — tracked forward and backward
Longitudinal records across all facilities
Monitored in real time with targeted follow-up

How it works

Three layers of process
transformation

Care is organised around defined clinical milestones instead of standalone visits. Each service area follows standardised protocols with clear checkpoints to ensure continuity and completion of care.

  • 12 CPHC service areas covered under structured protocols
  • Automated milestones for Ante Natal Care, NCD, immunisation, and chronic care
  • Standardised SOPs across all touchpoints
  • District Delivery Lead: District-level coordination, workflow management, stakeholder alignment.
milestone

The system actively reaches out to patients based on milestones and risk status, replacing passive follow-ups with structured engagement- Nurse led reminders and voice AI beyond facility hours.

All referrals are tracked end-to-end across facilities, with clear ownership at each step. A referral is complete only when follow-up care is delivered and recorded.

  • Forward referrals: PHC to CHC/DH, scheduled and tracked via PCCs
  • Backward referrals: DH to PHC for follow-up care
  • Dual-level triage ensures appropriate routing and reduces unnecessary referrals
close

Patient journey — Non-Communicable Disease (NCD)

How DiNC manages a citizen like
Velu from screening to ongoing care

journey

Identification & screening

ANM identifies Velu (36yr) as suspected diabetic during NCD household screening. Updates NCD app, books PHC appointment.

Existing prog.
journey

DiNC outreach & PHC visit

DiNC Nurse proactively counsels Velu on screening findings and next steps. PCC introduces himself as dedicated on-site support.

DiNC facility DiNC virtual
journey

30-day lifestyle monitoring

PHC doctor reviews history, advises 30-day diet & lifestyle changes. DiNC nurse follows up vitals regularly; CHO checks at sub-centre.

DiNC virtual
journey

Diagnosis confirmed

DiNC reminds for reassessment. Doctor confirms diabetes, starts metformin, schedules next review. PCC digitises records into HealthX.

DiNC facility
journey

Specialist referral

DiNC schedules specialist consultation at Area Hospital or virtual DiNC specialist if needed. Lab investigations coordinated.

DiNC facility DiNC virtual
journey

Ongoing care management

Prescription-refill reminders, lifestyle tele-counselling, quarterly check-ups. Routine PHC/AH consultations for continued care.

DiNC virtual

Patient journey — Maternal & Child Health (MC³)

How DiNC accompanies a mother like
Gowri from registration to postnatal care

journey

Registration

ASHA registers couple; DiNC notified automatically; nurse counsels on lifestyle.

DiNC virtual
journey

Pregnancy confirm & ANC

ASHA books PHC; DiNC ensures visit; USG scheduled.

DiNC facility DiNC virtual
journey

Trimester 1

ANC visit; IFA tablets; MCP card; investigations per protocol.

DiNC facility Existing prog.
journey

Trimester 2

USG; nutrition counselling; virtual Lamaze/yoga sessions for expectant mothers.

DiNC virtual AI
journey

Trimester 3

Anomaly scan at AH; birthing plan; PMSMA session; labour sign education

DiNC facility
journey

Delivery

Institutional delivery; baby registered in DiNC; immunisation milestones auto-created.

DiNC facility Existing prog.
journey

Postnatal

ASHA visits 48hrs post-discharge; DiNC virtual follow-up on breastfeeding, child development.

DiNC virtual AI
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KPIs Tracked in Real Time

Programme compliance as a tracked outcome

connected

ANC / PNC adherence

Milestone visits completed as per protocol schedule

continue

NCD follow-up rate

% of patients completing scheduled consultations as per care plan

closer citizen

Referral closure rate

% of forward referrals successfully completed and closed in the system

continue

Voice AI for care coordination

Cases managed at PHC level vs. those escalated unnecessarily

continue

Virtual consultation volume

Usage across V-Pod, toll-free, and outbound call channels

continue

Citizen satisfaction

Post-visit feedback collected through DiNC app and helpline

Doctor

What could this look like
in your district?

Discover how the DiNC model can help strengthen and transform healthcare delivery across your district or state through a data-driven, integrated, and outcome-focused approach.

If you would like to learn more about the model, explore its potential applicability in your context, or discuss partnership opportunities, we invite you to submit an enquiry. We will reach out to you to answer your questions, provide additional information, and discuss how the model can support your healthcare and development priorities.

ENQUIRE NOW