Whether you're looking to analyze broader trends within your patient population or assess the impact of specific Social Determinants of Health domains, our standardized, automated screening templates provide the flexibility to do both. These tools enhance social risk factor analysis, improve value-based care analytics, and support more accurate population health management.

Our seamless referral process ensures patients are efficiently connected with community-based organizations to address their diverse health-related social needs. By integrating healthcare referral management systems and social referrals, we streamline the connection between healthcare providers and community partners.

Track and monitor the outcomes of patient referrals to community-based organizations, ensuring continuity of care and facilitating follow-up to address any additional needs. Our patient referral tracking system enhances care coordination, supports healthcare & community integration, and ensures that patient adherence & follow-up automation drive comprehensive, holistic care.

Continuously expand and strengthen the community network, increasing access to a wide range of resources and services to meet the diverse needs of patients. By integrating multi-source healthcare data and fostering digital health & community partnerships, we enhance population health management and achieve Health Equity.

• Scaleable care coordination for greater operational efficiencies that grow with your organization
• Risk Stratification Care Gaps, Cost Ratio Analysis and more...
• Multi-source data integrations for longitudinal patient views (EMRs, Claims, Rx,...)
• Automated risk quantification, adherence monitoring, care gap identification and TCM
• Secure and cloud-based for centralized and accessible care management
• Customizable care-team dashboards with prioritized daily task lists
• Real-time monitoring and alerts to care team members
• Bi-directional, automated and interactive patient reminders, follow ups and adherence