Care Management
Coordinate care across the healthcare continuum, ensuring that patients receive timely and appropriate interventions, follow-up care, and support services.
Our Care Management module provides a scalable technology platform that unifies communication and care coordination. Revealing evidence-based care gaps, this module empowers you with patient/member care plans, case management notes, disease registries, and population risk scores.
- Automatically create individualized care plans based on clinical practice guidelines and evidence-based gaps in care
- Deliver coordinated, proactive, and patient-centered care that enhances the overall well-being of the population
- Engage in data-driven decision-making that enables you to prioritize interventions and prevent ER use, hospitalizations, and readmission
- Care plans respond dynamically as new data enter the platform
- Incorporate behavioral health and social determinants
- Integrate local, regional, and statewide-based social service resources
- Track referrals to completion
- Gain valuable insights into clinical performance, outcomes, and care delivery processes
- Enable care teams to manage, direct, and track patients from within a single, customizable care team dashboard
- Implement secure messaging getween authorized stakeholders and patients
- Maintains relevant materials—clinical and continuity-of-care documentation, lab and radiology reports, and more—with document storage
Identify barriers to care, engage patients, and improve health equity by integrating local, regional, and statewide-based social service resources, such as Meals on Wheels, patient transportation, and/or behavioral health centers, for referrals, which are then tracked to completion.
- Built-in patient assessments
- Complex case management tools
- Chronic care management (CCM) tools
- Self-management plans
