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

Categories

Solutions

Description

Product Description:

Our AI-powered Remote Patient Monitoring (RPM) and Chronic Care Management (CCM) platform is transforming how healthcare providers manage chronic conditions and monitor patients remotely. By leveraging AI, our solution empowers medical practices, clinics, and healthcare organizations to deliver proactive, data-driven care while maximizing efficiency and enhancing patient engagement.

About mobriseHealth, Inc.:

Our AI-powered Remote Patient Monitoring (RPM) and Chronic Care Management (CCM) platform is transforming how healthcare providers manage chronic conditions and monitor patients remotely. By leveraging AI, our solution empowers medical practices, clinics, and healthcare organizations to deliver proactive, data-driven care while maximizing efficiency and enhancing patient engagement.

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

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Product Capabilities

Personalized Engagement Tools Assist patients in tracking their health, setting reminders, and accessing their care teams. Smart Notifications for Better Adherence AI delivers tailored alerts to encourage medication compliance and care plan adherence. Inclusive and Intuitive Design The app is accessible to diverse patient populations, regardless of their technical skill level.

Real-Time Health Insights with AI Analysis Continuously monitor patient health using wearable devices, analyzing vital signs and detecting anomalies in real time. Predictive Alerts for Proactive Care AI predicts potential health risks before they escalate, enabling timely interventions and reducing hospitalizations. Optimized Care Coordination enhanced w/AI Agents Automatically identify high-risk patients and prioritize their care, ensuring seamless communication between care teams and patients.

AI-Driven Workflow Automation Automate repetitive tasks like care plan updates, appointment scheduling, and patient follow-ups, reducing administrative burden. Personalized Care Recommendations AI identifies tailored interventions based on patient-specific health data, ensuring individualized care that drives better health outcomes. Scalable, Resource-Efficient Solutions Use AI to manage larger patient populations effectively, making the most of your existing resources.

Personalized Engagement Tools Assist patients in tracking their health, setting reminders, and accessing their care teams. Smart Notifications for Better Adherence AI delivers tailored alerts to encourage medication compliance and care plan adherence. Inclusive and Intuitive Design The app is accessible to diverse patient populations, regardless of their technical skill level.

mobriseHealth's patient app is available in multiple languages to support a wide variety of patients. Also, supports patients with low health literacy being written at a lower grade level.

AI-Driven Workflow Automation Automate repetitive tasks like care plan updates, appointment scheduling, and patient follow-ups, reducing administrative burden. Minimize staff workload with AI-powered automation of administrative tasks. Easily integrate with EHRs.

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:
  1. Care Coordination for Patients with Multiple Chronic Conditions - Continuous monitoring of vital signs like blood glucose, blood pressure, and oxygen levels.
  2. Early detection of worsening conditions to prevent hospitalizations.
  3. Chronic Disease Management
  4. Post-Hospitalization Care
  5. Preventive Care and Wellness
Pediatric use cases:

None provided

Users:

Independent Practices, Health Systems, ACOs, FQHC

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:

Patient portal

EMR Integration & Relevant Hardware:

None provided

EMRs Supported:

Epic, Cerner, Meditech, Allscripts, NextGen, athena, GE, eClinicalWorks, McKesson, Other, Allscripts/Eclipsys, Athenahealth, Azalea Health/Prognosis, CPSI, Evident, Healthland, MEDHOST, MedWorx, QuadraMed, Point Click Care

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:

mobriseHealth is purpose-built for continuous patient monitoring, remote engagement, and chronic care management. It enables real-time data collection, actionable insights, and patient interactions outside of traditional clinical settings.

EHRs are primarily designed to store patient data and facilitate documentation during in-person visits. 

Differentiators vs Competitors:

As compared to our competitors, mobriseHealth provides easy to use, fully integrated RPM and CCM capabilities, allowing providers to track real-time health data and proactively manage chronic conditions with coordinated care plans in one unified solution.

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.

Health Equity

The mobriseHealth patient app is written at a 6th grade reading level as recommended by AMA.

The mobriseHealth Patient app is accessible in English and Spanish today with others to come in the future.

Yes. The mobriseHealth patient app is intended to overcome connectivity barriers faced by patients in rural communities, etc..

The mobriseHealth app considers social and behavioral determinants of health and adapts appropriately.

The mobriseHealth patient app builds trust with patients as does the provider portal.

This is a future release planned by mobriseHealth for patients and provider support.

Keywords

Images

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Videos

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OnCare360 TCM Patient Education Video.mp4

Downloads

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RPM and CCM Ebook
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OnCare360 Care Management Services.pdf

Alternatives

Company Details

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