OnCare360

• 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 Care plans are outdated, follow-ups are missed, and staff struggle to accurately track time for billing compliance with Chronic Care Management (CCM) services.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.

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

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.