Care Coordination

Effectively Manage Patient Populations

The Care Coordination module integrates workflows across the care continuum, automates workflows based on network care rules, enables identification, stratification and engagement of patients and high-risk members.

Intelligent Workflows

Identify at risk patients and implement immediate interventions

XCare Community is more than a “data dashboard”.  As a complete care management platform, it enables health networks to coordinate patient care across multiple settings.  By supporting seamless connectivity between hospitals, clinics and individual physicians, Care Community enables clinicians to develop intelligent workflows that identify the most at-risk patients, implement effective and immediate interventions, and measure their performance and financial outcomes.

Patient Engagement

Streamlined patient communications

With provider, care coordinator and patient portals, patient mobile applications and integrated visit surveys, XCare Community makes patient communication and engagement easy.

Seamless Transitions of Care

Effortlessly work with physicians across the care community

Streamline and improve transition care across partnering organizations to ensure better patient outcomes and minimize readmissions.

Social Services Integration

Address the whole person

The XCare Community system is designed to an individual’s “whole person” needs, including integration with community social service organizations to help address a patient’s social, economic, behavioral, isolation, and psychological issues.

A truly holistic approach to care management incorporates an individual’s social determinants – Do they understand their medications?  Are they actually taking them?  If not, why not?  Can they get transportation to their medical appointments? Are they ready to quit smoking? Do they live alone?   The XCare Community system addresses this need with built in assessment tools and links to community social service organizations, along with supporting proven evidence based protocols that can capture and manage the psycho-social variables as part of an individualized care pathway that addresses social and economic barriers to care plan compliance.

Protocols built on the seven domains of health: a person’s intellectual, emotional, physical, spiritual, social/cultural, occupational, and environmental needs, are highly tuned to a holistic approach to care management and offer the best opportunity to achieve triple aim goals of improved patient experience, optimized health outcomes, and lower cost.. It is not sufficient to simply know that a patient has asthma, is a diabetic, or is obese. Knowledge about the patient as a person – who they are, what made them that way, and why is equally critical if improved personal health outcomes are to be effectively achieved.