SageSurfer is a digital care coordination platform, focused on behavioural and mental health care. This patient-centred, team-based model aims to make it easier for patients, families, healthcare providers and community support providers to communicate and ensure that necessary actions are taken to support the patient’s care plan. Creating a unique care team involving healthcare providers, the patient and the patient’s own community of peers, family and friends, this AI-driven tool is integrated with health records and supports professionals to monitor progress between visits and identify and manage risk. Patients receive an assessment and can be directed towards self-care activities and local support via the tool. They can also communicate directly with their health care team via video, audio or a chat function. Personalised to the patient, it is able to support patients with complex mental health issues but Sagesurfer also work closely with schools and universities to build care teams from an early stage in a patient’s journey. The app is currently being used with around 4000 patients and SageSurfer estimates that the tool reduces emergency department visits by 35%, with patient engagement rates between 85-90%.