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Description
Compatibility Level
Clients
Product Capabilities
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EHR integrations
Client types
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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:

Coordinista is mobile-first platform built for mobile and hybrid primary and post-acute care teams managing high-touch populations. 

Nurse designed, Coordinista shifts data and workflows to the point of care, helping teams improve outcomes, stay compliant, and strengthen their bottom line.

Lightweight and EHR-agnostic, Coordinista empowers field teams to self-manage schedules and reduce administrative burden and drive time while giving organizations full transparency and audit-ready reporting. Its robust field-based self-management system can also be used as a central command center, flexing as needed across different care delivery models even within the same organization.

For Primary Care: Coordinista ensures accurate condition capture with embedded coding tools at the point of care, safeguarding risk adjustment integrity and aligning reimbursement with true patient acuity. It also streamlines mobile phlebotomy, eliminating manual faxes and driving lab order data directly into workflows.

For Care Management: Coordinista streamlines operations for your team and accelerates transitions of care continuity and responsiveness, like enabling medication reconciliation in the home within 48 hours of discharge, improving outcomes and boosting downstream patient satisfaction and CCM engagement while reducing costly readmissions and ER visits.

With customizable workflows, real-time audit safeguards, and seamless interoperability, Coordinista supports multiple lines of business while reducing waste. Every encounter, whether in-person, telephonic, or administrative, is tracked by time, duration, and geo-location, with data instantly available on the administrative dashboard. A built-in mileage tracker makes reporting effortless for clinicians and administrators alike.

Coordinista helps care teams deliver higher-quality, compliant, and efficient care anytime, anywhere.

About Coordinista:

Coordinista is a first-of-its-kind, mobile-first platform built for mobile and hybrid primary and post-acute care teams managing high-touch populations. Nurse designed, it brings data and workflows to the point of care, helping teams improve outcomes, stay compliant, and strengthen their bottom line.

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

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Clients

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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:

Care Management Teams Serving High-acuity Populations

Coordinista streamlines CM and TOC operations and ensures accountability and continuity. Teams can complete critical tasks—like in-home medication reconciliations within 48 hours of discharge, leading to reduced readmissions and ER visits, and boosting patient engagement. The result: stronger quality scores, higher satisfaction, and better outcomes for both patients and organizations.

 

Mobile Primary Care Teams (ISNP & DSNP Populations)

Coordinista equips mobile and hybrid primary care teams to deliver seamless primary care, care management, and transitions of care across wide territories. By unifying scheduling, documentation, and communication, providers can optimize resources, ensure continuity between teams, and maintain full transparency while serving complex populations.

 

HCC Recapture Programs

Coordinista helps teams maximize accuracy and efficiency in HCC recapture. In one case, a mobile provider team completed 1,400+ chronic disease assessments across 40+ facilities in just 23 days—analyzing 1,600+ historical ICD-10 codes and increasing an ISNP plan’s RAF score by 16%. At the point of care, embedded coding tools ensured actionable, accurate condition capture, protecting risk-adjustment integrity and aligning reimbursement with actual patient acuity.

 

Mobile Phlebotomy

Coordinista modernizes mobile phlebotomy by eliminating manual fax and email workflows. Lab orders flow directly to the point of care, improving turn-around times, accuracy, and productivity.

Pediatric use cases:

Supports care management associated with Medicaid and pediatric populations. 

Users:

Coordinista has delplyed with mobile providers across MI, WV, OH, will be deploying soon in IN and MD. Coordinista provides value for each level of stakeholders.

Clinicians in the Field

 

What they need: Flexibility, efficiency, and less administrative burden so they can focus on patients.

How Coordinista helps:

  • Mobile-first tools making it fast and easy to self-manage caseloads and schedules.
  • Point-of-care documentation with embedded coding tools to capture real patient acuity.
  • Integrated workflows for labs, phlebotomy, and transitions of care—no more juggling faxes or duplicate entry.
  • Built-in mileage tracker and time capture to simplify reporting.

Impact: More time with patients, less administrative burden, and confidence that nothing slips through the cracks.

    

Supervisors / Care Team Managers

What they need: Visibility, accountability, and seamless coordination across teams.

How Coordinista helps:

  • Real-time transparency into schedules, caseloads, and field activity.
  • Dashboards that show productivity, engagement, and compliance at a glance.
  • Ability to flex between self-managed and centrally scheduled models—even within the same organization.
  • Customizable workflows and alerts to ensure deadlines (TOC, CCM, quality tasks) are consistently met.

Impact: Stronger team performance, faster responsiveness to patient needs, and improved quality scores.

 

Administrators / Operations Leaders

What they need: Compliance, financial integrity, and efficient use of resources.

How Coordinista helps:

  • Audit-ready reporting of all encounters (time, duration, geo-location) in real time.
  • Accurate condition capture to protect risk-adjustment integrity and align reimbursement with true acuity.
  • Seamless interoperability with any EHR or data system to reduce manual work and improve security.
  • Operational insights that identify waste and highlight opportunities for optimization.
  • Improved outcomes, quality, and compliance, resulting in more savings, increased revenue, and better margins. 

Impact: Lower costs, stronger compliance, improved reimbursement, and data-driven decisions to scale efficiently.

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, Ancillary EMR, Pop health platform, Home health, ADT

EMR Integration & Relevant Hardware:

Use case dependent

EMRs Supported:

Athenahealth

Hardware Compatibility:

Desktop, Mobile / Tablet (native app)

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:

Coordinista's interoperability technology and capabilities are amongst the best in the word. Coordinista can integrate with any standard or format, whether HL7, FHIR, CCDA, or others for secure and seamless bi-directional data flow. 

Differentiators vs Competitors:

Coordinista's advantage is empowering point-of-care decisions-making and deployment strategy for best outcomes. 

Operations

  • Centralized Dispatch Systems: Centralized deployment, costly schedulers & overhead
  • Decentralized Dispatch Models: High manual administrative burden, lacks field transparency and insight

Coordinista: Decentralized & centralized deployment, schedulers not required, transparent, streamlines admin, reduces overhead

Data

  • Centralized Dispatch Systems: Scheduling related data
  • Decentralized Dispatch Models: Siloed data, limited analytics

Coordinista: Real-time actionable diagnosis, lab orders, patient risk level, hospitalizations, services, mileage, and patient data and analytics

Technology

  • Centralized Dispatch Systems: Single system, complex for users, scheduling capabilities and patient notification
  • Decentralized Dispatch Models: Multiple, clunky, disconnected tools, not healthcare-first

Coordinista: Clinician friendly, end-to-end operations, healthcare dedicated, mobile-native, HIPAA, Integration ready for any ecosystem

Value

  • Centralized Dispatch Systems: Scheduling only, often disliked by clinicians and patients
  • Decentralized Dispatch Models: Inefficient, missed compliance, higher patient admissions

Coordinista: Efficient, flexible for dual deployment ops, resource utilization insight for best patient outcomes

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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Case Study_ Avail Health WV.pdf
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OnCare360 Care Management Services.pdf

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