Care plan orchestration, task assignment, and risk stratification for chronic care and value-based care programs, built on configurable care pathways rather than a single hardcoded workflow.
Chronic care and value-based programs rarely run on one workflow. A diabetes pathway, a post-discharge transitional care pathway, and a behavioral health pathway all need different templates, different task cadences, and different risk models, but teams end up hand-coding each one separately. This framework gives you a single orchestration engine with configurable pathways underneath it, so a new program is a configuration change, not a new build.
It ships with a documented data model, HCC risk-adjustment scoring, and CCM/TCM billing code mapping built into the same care-plan layer that tracks task completion. Time-based billing thresholds are derived from real care team activity, not reconstructed after the fact.
Pre-built pathway templates for common chronic and transitional care programs, each configurable in structure, task cadence, and escalation rules without custom code.
HCC-based risk scoring surfaces which patients need attention first, feeding directly into task prioritization for the care team.
Assign, reassign, and track tasks across a care team with due dates, escalation paths, and completion tied back to the patient's care plan.
A shared workspace gives nurses, care coordinators, and physicians visibility into the same patient record and task list, reducing duplicate outreach.
Time-based billing thresholds for Chronic Care Management and Transitional Care Management are tracked from actual task and care-plan activity.
A configuration layer connects care pathways to your EHR and existing care coordination workflows, so the framework extends your process rather than replacing it.
| Dimension | Details |
|---|---|
| Data standard | FHIR R4 (CarePlan, CareTeam, Task, RiskAssessment) |
| Risk scoring | HCC risk adjustment model |
| Task orchestration | Configurable cadences, escalation rules, multi-role assignment |
| Billing | CCM and TCM time-based code mapping |
| Compliance | HIPAA, BAA-ready hosting |
| Extensibility | API access for new pathways and scoring models |
Match your care programs and cohorts to the pathway template model.
Configure pathway templates, task cadences, and connect your EHR.
Run pathways against test cohorts before anything touches live patients.
Staged rollout with live monitoring and a rollback plan in place.
Yes. Each program runs as its own configurable pathway template, so different task cadences, escalation rules, and risk models can coexist on the same orchestration engine without interfering with each other.
The framework uses an HCC-based risk adjustment model to score patients, which feeds directly into task prioritization so the care team sees highest-risk patients first.
It tracks time-based billing thresholds for Chronic Care Management and Transitional Care Management from actual task and care-plan activity, and makes that data exportable to your billing workflow.
Yes. Care coordinators and administrative staff can be assigned tasks alongside clinical roles, with role-based permissions controlling what each can view or edit on a patient's care plan.
Yes. Both frameworks share a common data model, so RPM alerts can trigger tasks directly inside a patient's care pathway without duplicating records or building a separate integration.
Book a discovery call, we'll map your use case to a realistic configuration scope and deployment timeline.