Population Health Management Tools to Help Identify and Resolve Disparities in Health Care

Give your clinicians and administrators access to patient data in real-time to help optimize care transitions and communication for better outcomes, reduce readmissions, improve patient engagement, and maximize earnings.

Unmatched Network Scale & Activation

#1 in Post-Acute Network Coverage With 70% Market Share Across 22,000+ Skilled Nursing and Long-Term Care Facilities, and 3,000+ Hospitals. Active Today.

Support Your Value-Based Care Reimbursement Strategy With PHM Tools

With the healthcare industry shifting to a value-based care model, it’s important to have tools that give you a comprehensive view of your patient population’s data in real-time, help identify gaps in care, and unify a patient’s care team with shared insights.

Our population health management software provides your team access to the right data that helps improve patient outcomes and satisfaction, enhance care quality, and lower healthcare costs. With real-time patient data and proactive alerts, easily identify and focus care on at-risk patients who may require more attention, helping to reduce avoidable hospital admissions and readmissions.

Key Features of Our Population Health Management Software

Real-Time Data and Notifications Sent In-Workflow to Optimize Transitions of Care

Learn about your patients’ acute and post-acute encounters by receiving customized reports and notifications delivered to care teams through curated methods, including integrating with your EHR.

Advanced Analytics, Intelligent Risk Scoring, and Chart-Level Data to Reduce Avoidable Readmissions

Easily identify and zero in on at-risk patients who may require additional attention. Help your care managers prioritize their tasks and better determine when to focus on patients with higher risks of readmission with access to real-time analytics and clinical data.

Collaborative Shared Insights to Improve Care Outcomes and Patient Satisfaction

Ensure the right care is provided at the right time to drive improved clinical and financial outcomes with shared individual patient insights from emergency departments, skilled nursing facilities, and other providers within and outside of your network.

Insightful Dashboards to Understand and Manage Your Network From a Single Pane of Glass

Understand how your skilled nursing facility network is performing with respect to key metrics including length of stay and readmission rates buy leveraging live, automated dashboards. Identify, monitor and drill down on trends noticed instead of waiting for claims data.

Proven Outcomes

78%

reduction in all-cause 30-day readmissions at hospital partner in Oregon

60%

reduction in avoidable readmissions at skilled nursing provider partner’s 3 facilities in Oregon

70%

reduction in post-acute readmissions within the first 30 days

25%

reduction in all-cause 30-day readmissions at hospital partner in southwest Washington

$6.5M

reduction in the cost of care and a 7% drop in avoidable admissions at ACO in Washington

93%

of transitions fully electronic, saving time and reducing mistakes