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Solutions
Description
Compatibility Level
Clients
Product Capabilities
Use cases
EHR integrations
Client types
Differentiators
Keywords
Media
Company details
Jump to:
Categories
Solutions
Description
Compatibility Level
Clients
Product Capabilities
Use cases
EHR integrations
Client types
Differentiators
Keywords
Media
Company details

Categories

Solutions

Description

Product Description:

With exciting advances is AI, NLP, machine learning, patients can communicate via voice and/or text, 24/7, extending the reach of physicians and care teams to support self-care from home. YODHA is designed to create a trnsformative patient experience that empowers them to adopt new healthy habits that improve their health and wellness. while reducing their health risk. 

As a customizeable platform, engagement strategies can be delivered to achieve a wide range of business goals. For those focused on reducing the incidence and cost of chronic diseases, our platform applies proven behavior science methodologies to proactively reach at-risk patients and engage them,regardless of their initial level or awareness or motivation. Our behavior science driven approach helps them build motivation and self-confidence to set short-term achieveable goals that support their journey to better health and wellness.  

YODHA can also be deployed to streamline care processes and improve performance on quality indicators including supporting transitions to home following hospital discharges, following up after ER visits, closing care gaps, improving medication compliance and administering surveys. Our platform also offers a new excitijng opportunity to view educational content on demand, deliverered by a trained AI video generator and/or traditional videos and pdfs from our library.  

By integrating available claims, EMR,, lab data with patient provided chats, we create comprehensive patient profiles. Levels of health risk, motivation, self-confidence, mental/emotional health and change readiness to deliver are identified to create personalized approaches to create new healthy habits spanning food/nutrition choices, levels of physicial activity, and emotional control, 

Our technology stack is supported on the AWS platform and includes use of a constrained large language modeel (LLM) conversational AI and an AI video generator that supports voice and text interactions with our YODHA chat bot on smart phones, tablets and desktops. The product integrates patient data from EMR and claims records with information that is gathered in structured chat interactions to tailor personalized engagement strategies that align with the health care organizations patient engagement goals.

About AI Health Solutions, Inc.:

AI enabled and behavior science drive patient activation platform extends care team resource by supporting prevention and management of chronic diseases, closing care gaps, reducing preventable readmissions, improving CHAPS and quality metrics through virtual care engagement from home.

Product Description:

OnCare360 addresses the patient’s journey between point-of-care visits with a continuous care management platform that captures and transmits daily health data through devices, wearables, and patient interactions. OnCare360 takes a 360-degree approach to managing value-based care by combining Care Management (CCM, RPM, TCM, PCM, RTM), medication, adverse event, and general wellness, clinical communication, and data analytics to create a circle of support between patients, providers and payers.

About OnCare360 Inc.:

OnCare360 addresses the patient’s journey between point-of-care visits with a continuous care management platform that captures and transmits daily health data through devices, wearables, and patient interactions. OnCare360 takes a 360-degree approach to managing value-based care by combining Care Management (CCM, RPM, TCM, PCM, RTM), medication, adverse event, and general wellness, clinical communication, and data analytics to create a circle of support between patients, providers and payers.

Compatibility level

Select which hospital or health system you work at and see a personalized compatibility level.

Clients

Select which hospital or health system you work at and see the client list

Product Capabilities

OnCare360 collects a wide range of data, including clinical information such as vital signs, diagnoses, medications, and post-discharge details; care management data like time spent on coordination and care plan updates; and patient-generated health data from RPM and RTM devices. It also gathers social determinants of health (SDOH) data, including housing, transportation, and other socioeconomic factors, along with behavioral health metrics such as mental health screenings and care plans. Preventive care data, such as Health Risk Assessments (HRA), Fall Risk Assessments (FRA), and Advance Care Planning (ACP) directives, are also collected, as well as engagement data from patient portals, communication logs, and reminders. Additionally, OnCare360 tracks billing and compliance data, including CPT codes and audit-ready documentation.

OnCare360 provides advanced analytics to support comprehensive care management and decision-making. These analytics include real-time dashboards for tracking patient outcomes, care plan adherence, and program performance across RPM, CCM, TCM, and other CMS programs. Risk stratification tools identify high-risk patients for targeted interventions, while utilization metrics assess resource efficiency and care delivery effectiveness. The platform also offers insights into social determinants of health (SDOH), highlighting barriers to care and tracking the impact of interventions. Additionally, OnCare360 generates compliance reports, billing accuracy metrics, and CPT code utilization summaries to ensure regulatory alignment and optimize reimbursements. This robust analytics suite enables providers to measure outcomes, improve workflows, and deliver data-driven care.

OnCare360 enables seamless bidirectional communication between healthcare providers, patients, and care teams to enhance coordination and engagement. The platform integrates secure messaging, patient portals, and real-time alerts to facilitate ongoing interactions. Providers can send care plan updates, educational materials, appointment reminders, and alerts to patients directly through the system, while patients can respond with questions, upload health data, or report symptoms via the portal or integrated communication tools. For care teams, OnCare360 supports collaborative workflows, allowing providers, nurses, and social workers to share updates, assign tasks, and communicate in real time. This two-way communication ensures that all stakeholders stay informed and aligned, fostering timely interventions and better care outcomes.

OnCare360 ensures providers can engage eligible patients through cellular-connected devices, eliminating the need for Wi-Fi and enhancing accessibility for underserved populations. For patients with higher technical literacy, OnCare360 offers an intuitive mobile app to streamline access to care plans, reminders, and educational resources. This combination ensures tailored engagement for diverse patient needs.

OnCare360 offers pre-built, condition-specific care plans and pathways that are fully customizable to meet the unique needs of each patient. These templates are designed to support clinical decision-making and streamline patient engagement, providing actionable guidance for care delivery. Integrated directly into the platform, these care plans align with automated workflows, ensuring seamless implementation while enabling providers to personalize interventions, enhance adherence, and optimize outcomes with ease.

OnCare360 seamlessly integrates with existing EHR systems, supporting both HL7 file-based integration and SMART on FHIR protocols. This interoperability ensures smooth data exchange, enabling providers to synchronize patient information, care plans, and clinical workflows directly within their EHR environment. By leveraging industry-standard frameworks, OnCare360 enhances operational efficiency and reduces duplication of effort, allowing healthcare teams to focus on delivering high-quality, coordinated care.

OnCare360 streamlines logistics management, staff training, patient onboarding, and ongoing tech support to enhance the clinician and patient experience. The platform provides intuitive workflows that simplify patient onboarding, ensuring smooth enrollment in care programs with minimal administrative effort. Staff training modules offer step-by-step guidance on using OnCare360’s features, enabling care teams to adopt the platform quickly and effectively. Additionally, the system includes robust tech support, with dedicated resources to address patient and provider needs, reducing disruptions and ensuring seamless operation.

OnCare360 leverages AI-based assistants, tailored learning content, and educational materials to engage patients and support behavior change. The platform delivers personalized insights, automated reminders, and easy-to-understand resources, empowering patients to track progress, set goals, and stay motivated in achieving better health outcomes.

Use Cases

Description:

AI enabled and behavior science driven digital Health platform that extends the reach of health care organizations to personalize patient engagement and activation that closes care gaps, prevents and manages metabolic conditions, and reduces preventable readmissions while improving patient satisfaction and loyalty.

Pediatric use cases:

None provided

Users:

Patients, Care Teams, Physicians, Health Coaches  

Description:

• A primary care practice is overwhelmed with the administrative burden of managing a large population of patients with chronic conditions like diabetes and hypertension. Care plans are outdated, follow-ups are missed, and staff struggle to accurately track time for billing compliance with Chronic Care Management (CCM) services. This results in poor patient outcomes and underutilization of reimbursement opportunities.

• A cardiology practice focuses on managing patients with advanced heart conditions but faces challenges in coordinating Principal Care Management (PCM) for these high-risk individuals. Providers find it difficult to track detailed interactions, update care plans, and collaborate with primary care teams, leading to gaps in care and reduced efficiency in managing a single complex condition.

• A regional hospital experiences high readmission rates and struggles to optimize patient length-of-stay due to ineffective Transitional Care Management (TCM). Many patients discharged after acute care fail to schedule follow-ups, adhere to discharge instructions, or receive timely medication reconciliation. Additionally, inefficient discharge planning leads to extended hospital stays, straining resources and affecting patient flow. Without a centralized system to monitor post-discharge care, track follow-up visits, and coordinate transitions, the hospital faces challenges in improving recovery outcomes, reducing readmissions, and achieving value-based care benchmarks.

• A rural health clinic struggles to monitor patients with chronic diseases due to limited access to in-person care and delayed identification of worsening symptoms. Patients are often unaware of their health trends, leading to avoidable complications. The clinic needs a solution to integrate FDA-approved RPM devices and deliver real-time insights for timely interventions.

• A payvider serving a diverse population finds that many patients face significant social determinants of health (SDOH) barriers, such as transportation challenges, food insecurity, and housing instability. These barriers prevent patients from adhering to care plans and attending follow-ups, resulting in increased healthcare costs and poor outcomes. The organization lacks tools to systematically capture and address these non-medical factors.

Pediatric use cases:

None provided

Users:

Physician Practices, Hospitals, Health Systems, Accountable Care Organizations, Primary Care Providers, Speciality Providers

EHR Integrations

Integrations:

Acute care EMR, Ambulatory EMR, Patient portal, Pop health platform

EMR Integration & Relevant Hardware:

Use case dependent

EMRs Supported:

Epic

Hardware Compatibility:

None provided

Integrations:

Acute care EMR, Ambulatory EMR, ADT, Website / public online sources

EMR Integration & Relevant Hardware:

Recommended, but not required

EMRs Supported:

Epic, Cerner, eClinicalWorks, Allscripts, Meditech, NextGen, Athenahealth

Hardware Compatibility:

Desktop, Mobile / Tablet (web optimized), Mobile / Tablet (native app), Other

Client Types

Differentiators

Differentiators vs EHR Functionality:

Use of conversational AI chats to learn about patient concerns, aspirtaitons, change readiness and sources of potential motivations to improve their health from home with personalized virtual care, coaching, education and behavior change.  

Differentiators vs Competitors:

Use of clinical and emtional/ behavioral data to develop personallized patient activation strategies. Integration of a constrained LLM to enable patients to ask general health questions. Use of AI video generators to provide an enaging way to share vetted informtion appropriate for the patient's condition. Omni-channel capabilites support voice and text interactions. Provision of patient abdcare team portals to enable care management

Differentiators vs EHR Functionality:

OnCare360 enhances care management by addressing key gaps:

1. Comprehensive Care Management: Specialized tools for CMS programs like CCM, RPM, TCM, and SDOH, including workflows, time tracking, and care plan templates.

2. Automated Compliance: Built-in CPT code tracking and billing workflows ensure accurate reimbursements and CMS compliance.

3. Patient Engagement: Offers portals, reminders, and secure messaging for proactive communication and improved adherence.

4. Advanced Analytics: Real-time dashboards track care outcomes, program performance, and at-risk patients.

5. SDOH Integration: Dedicated tools to assess and address social barriers to care, linking patients to resources.

OnCare360 complements EHR systems by focusing on care delivery, compliance, and patient-centric tools.

Differentiators vs Competitors:

OnCare360 stands out with its comprehensive, integrated platform designed to streamline workflows and improve patient outcomes:

1. All-in-One Platform: Combines tools for RPM, CCM, TCM, PCM, AWV, SDOH, ACP, and more, eliminating the need for multiple systems.

2. Program-Specific Features: Tailored workflows, care plan templates, and automated time tracking for each CMS program ensure ease of implementation and compliance.

3. Patient Engagement Tools: Secure portals, reminders, and educational resources promote adherence and satisfaction, surpassing basic communication solutions offered by competitors.

4. Compliance Automation: Preloaded CPT codes, billing accuracy checks, and audit-ready documentation reduce errors and maximize reimbursements.

5. SDOH and Holistic Care: Advanced tools to assess and address non-medical factors, linking patients to resources and improving health equity.

6. Scalability and Flexibility: Suitable for small practices, large health systems, and ACOs, with customizable workflows for diverse needs.

7. Real-Time Insights: Analytics dashboards provide actionable data on care outcomes, performance metrics, and patient risks.

OnCare360 delivers unmatched versatility, compliance, and patient engagement features.

Keywords

Images

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Videos

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OnCare360 TCM Patient Education Video.mp4

Downloads

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OnCare360 CCM.pdf

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Company Details

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