HealthCollaborate™ Transitional Care Management Application



It is no secret that high-performing healthcare providers and payers must proactively engage, monitor and navigate population groups with complex medical, behavioral, and long-term care needs through multiple care settings.

“Single platform to coordinate, manage & track patient care transitions from hospitals to post-acute care settings.”


Effective transitional care management plays a major role in improving population health, maximizing reimbursements and reducing costs for Payers, Accountable Care Organizations, hospitals, physician networks, and Transitional Care Service Providers.


Health BI has developed an integrated suite of applications (HealthCollaborate™) that enables healthcare organizations and health plans to coordinated, manage and monitor patient care transitions anywhere/anytime.  This EMR neutral solution, aligns patient-specific transitional care needs with data analytics, customized workflows, care team collaboration and patient engagement tools to efficiently navigate patients from hospitals to ambulatory and community care settings.


HealthCollaborate™ improves your clinical and financial outcomes with easy integration into your clinical workflow.


HealthCollaborate™ enables healthcare providers and payers to:


  • Manage & Track Care for Large Patient Populations
  • Aggregate, Analyze and Report Population Health Data
  • Create & Manage Workflows and Care Plans
  • Proactively Engage Providers and Patients
  • Achieve the Triple Aim
  • Improve Patient Satisfaction Scores
  • Report Care Coordination Quality Metrics


HealthCollaborate™ can have direct impact on financial incentives, including:


  • Readmission Penalties
  • Medicare Shared Savings Programs
  • Bundled Payments (or Episode-Based Payments)
  • Pay-for-Performance / Hospital Value-based Purchasing


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Analytics & Reporting

Population Health Data Analytics & Reporting

Care Transitions starts from the time patient enters the hospital and continues through

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multiple layers of ambulatory care settings. Healthcare organizations and payers must access multiple data sources to identify and stratify patients’ risk and keep track of all transitional care activities.


By combining ADT, clinical and claim data, HealthCollaborate™ runs real-time data analytics and reporting to identify at-risk patients, assign the right workflows and turn data to action.  HealthCollaborate™ actively tracks all care transitions & coordination interactions and encounters with patients, caregivers, providers, payers and facilities. HealthCollaborate™ provides organizations complete visibility to post-acute patient care management data, goals, gaps and outcomes.



The Data Analytics Module includes:


  • Data Warehousing, Analytics & Reporting
  • Patient Identification & Stratification
  • Transitional Care Coordination Analytics & Reporting
  • Measuring & Reporting Performance
  • Measuring & Reporting Quality Metrics
  • At-risk patient Scoring & Comorbidity Index
  • Readmission Probability
  • High Risk Flagging
  • Cohort Categorization
  • Dynamic Risks Assessments
  • Utilization Reporting
  • Patient Outcomes Reporting
  • Patient Outreach Reporting
  • Care Coordination Efforts
  • Readmission Breakdown
  • Population Reporting




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Event Notification System

Event Notification System

Many healthcare providers and health plans are unaware of their patients’ ER visits or hospital admits and discharges. The ability to quickly notify and mobilize the care team can reduce hospital readmissions and avert millions of dollars of spending on preventable hospitalizations.



HealthCollaborate™ Event Notification System (ENS) connects, alerts and updates healthcare providers and payers of patients ADT events and outcomes. This approach insures quick deployment of the care team and proactive engagement, monitoring and navigation of patients through the continuum of care.


Through integration and processing of HL7 ADT messages, HealthCollaborate™ (ENS) provides real-time or daily batch notifications with critical information to payers, private physicians, care management teams, ACOs–alerting them of their members’ acute encounters with participating hospitals.


“A complete event-based notification system for HIEs, Hospitals, Payers and Providers.”


The HealthCollaborate™ Event Notification System can be deployed as a standalone system or as part of the complete Care Transition Management System. All notifications are delivered via HealthCollaborate™ multi-channel secure messaging platform.



HealthCollaborate™ Event Notification System helps healthcare payers and providers to:


  • Integration with HIEs
  • Create Master Patient-Provider Index
  • Receive detailed notifications of acute care episodes
  • Be notified of readmissions
  • Quickly deploy a transitional care team
  • Timely execution of care plans
  • Improve patient satisfaction scores


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Workflow Manager

Care Transition Workflow Engine

The HealthCollaborate™ Transitional Care Management Application creates a collaborative network of providers-payers-patients and enables care coordinators to create various customized transitional care workflows based on patients’ care plans.


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HealthCollaborate™ then automatically executes each workflow, enabling care coordinators to manage and monitor patients care transitions across the continuum of care on the navigation dashboard.


HealthCollaborate™ delivers your care coordination team a software application that includes:


  • Customizable Care Transitions workflows
  • Patient Navigation Dashboard
  • Multiple Data Source Integration
  • Standardized Care Coordination Models (and more…)



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Task Manager

Care Transition Task Manager

The HealthCollaborate™ Transitional Care Management Application provides the care team with single platform to execute and manage care transition tasks and activities, eliminating manual and fragmented processes. The application is designed to bring together all necessary tools and processes for seamless interdisciplinary collaborative care delivery.


HealthCollaborate™ Care Transition Task Manager Module includes:


  • Appointment Requests and Scheduling
  • Appointment Notifications, Reminders and Follow-Ups
  • Patient Monitoring
  • Medication Notifications/Monitoring
  • Automated Post Discharge Assessment Calls and Follow-Ups
  • Patient Education
  • Medication Information
  • Assessments & Notes
  • PHR (and more…)


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Engagement Platform

Patient Engagement Platform

Your patient engagement strategy should rely on actively pushing and pulling information to and from patients through different means of communication. That can be achieved by deploying technology solutions that connect with providers and patients based on the best method of communication available to them. The idea of waiting for patients to access portals to be engaged is a failure.


HealthCollaborate™ multifaceted patient engagement technology connects with patients and providers based on users’ preferred method of communication.


This approach helps healthcare organizations to manage provider-patient engagements based on users’ preference and convenience.


HealthCollaborate™ Provider-Patient Engagement Platform includes:


  • Interactive Voice Recognition (IVR)
  • Secure Mobile Messaging
  • Secure Email
  • Secure Provider/Patient Portals
  • e-Referrals
  • SMS (Text Messaging)
  • e-Fax


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