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Care Coordination

Facilitate and Integrate Comprehensive Patient Care

Care Coordination is a flexible, rules-driven care coordination system designed specifically for physician groups, hospitals, health systems, and provider-led health plans to succeed with 30-90 day episode management, whether for ensuring bundled payment profitability, maximizing ACO and health plan savings, managing post-acute costs, or reducing readmissions.

Using interoperability standards inherent in every certified EHR, Care Coordination integrates with both the EMR of the hospital/health system and the EMRs of community providers to streamline coordination and to share necessary clinical information required for effective care transitions. In addition to provider coordination, Care Coordination delivers targeted messages to patients and caregivers, largely through email and text, based on the care plan rules.

Providers, payers, and other at-risk entities derive measureable benefits from Care Coordination, including:

  • Certainty of care plan compliance, even 30-90 days after leaving the hospital
  • Bundled payment profitability
  • Fewer avoidable readmissions
  • Reduced post-acute care costs
  • Improved patient engagement through more efficient use of care managers
  • Incremental revenue from billing of higher value Transitional Care Management (TCM) visits
  • Care plan compliance captured as structured data for use in analytics

The Care Coordination solution features the following:

  • Configurable rules engine
  • Closed-loop messaging and alerts
  • Dashboard view of priority work
  • Direct-enabled EMR integration
  • Scalable deployments
  • Compliance tracking for Transitional Care Management billing (CPT 99495, 99496)

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