A complete operational workspace for readmission prevention.
Designed with AAAs and community organizations — not for hospitals.
Configurable workflow
Default 11-status pipeline from Referral Received through Closed. Admins can rename, reorder, or hide statuses without code changes.
Client & caseload management
Demographics, payer, PCP, caregiver, chronic conditions, social needs, consent — all on one record with full activity timeline.
Standard built-in forms
Referral intake, eligibility & enrollment, consent, risk assessment, ED utilization, medication reconciliation, social needs, encounter notes, and closure.
Risk scoring engine
Weighted, configurable, transparent. Each tier shows exactly which factors drove the score so coaches know where to intervene.
Task automation
Risk-based tasks, missing PCP follow-up, medication concerns, stalled cases, and supervisor escalations — all automated.
Encounter logging
11 encounter types covering phone, home visit, care coordination, transportation, caregiver coaching, and more.
Care planning
Structured problems, goals, interventions, and progress notes tied to the 30-day episode.
Document management
Discharge paperwork, signed consent, medication lists, and external referrals — categorized and tied to the client and episode.
Reporting & exports
30-day readmission, active caseload, high-risk, overdue tasks, staff activity, referral source, outcomes — with CSV export.
Multi-tenant SaaS
Strict data separation by organization. Branding, program name, episode length, and automation timing are per-tenant.
HIPAA-oriented controls
Unique accounts, role-based least-privilege, row-level security, audit trail, session timeout, and consent capture.
Outcome tracking
Every closure captures readmission, ED revisit, PCP follow-up, medication reconciliation, and successful outreach.