Care Management Framework

Yes. The framework is built around a single orchestration engine with configurable pathways underneath it, so multiple programs can run side by side on the same instance. A diabetes pathway, a post-discharge transitional care pathway and a behavioral health pathway each run as their own pathway template, with their own task cadences, escalation rules and risk models. Because each program is configured as a template rather than hard-coded, they coexist without interfering with each other: changing the cadence of one pathway does not alter another. This is the main reason the framework exists. Care and value-based programs rarely share a single workflow, and teams that build each one separately end up maintaining several codebases that drift apart. With one engine, adding a new program is a configuration change rather than a new build, which also keeps the data model consistent across programs and makes it simpler to report across them. Pathway structure, task cadence and escalation rules are all configurable without custom code, and the framework offers API access if you need to add new pathways or scoring models beyond the templates. Role-based permissions let you control which staff see and edit which patients' care plans in each program. Your programs and how they should map to pathway templates are worked out during the Fit Assessment, the first step of the deployment path.

The framework uses an HCC-based risk adjustment model to score patients. HCC stands for Hierarchical Condition Category, a widely used way of expressing how much clinical risk and expected care need a patient carries based on their documented conditions. The score is not kept in a separate report. It feeds directly into task prioritization inside the care-plan layer, so the care team sees the highest-risk patients first when they open their work for the day. That connection is what makes the score useful: a number on a dashboard does not change behavior, but a worklist ordered by risk does. Scores are stored using FHIR R4 RiskAssessment resources alongside the CarePlan, CareTeam and Task resources that make up the rest of the data model, so risk information sits in the same structure as everything else the care team works with. Because the framework exposes API access for new pathways and scoring models, the scoring approach can be extended where your program needs something beyond the HCC model. Risk scoring supports prioritization and does not replace the care team's clinical judgment about an individual patient. How scoring should be applied across your programs is part of what gets mapped during the Fit Assessment, and it is then configured and validated before go-live.

It tracks the data that billing depends on, and makes that data available to your billing workflow, but it does not submit claims on your behalf. Chronic Care Management and Transitional Care Management are both time-based services, which means eligibility depends on being able to show how much qualifying care team time was spent and what was done. In many organizations that evidence is reconstructed after the fact from notes, calendars and memory, which is slow and error-prone. In this framework, the billing layer is built into the same care-plan layer that tracks task completion, so time-based thresholds are derived from actual task and care-plan activity as the work happens. CCM and TCM codes are mapped using CPT and HCPCS standards, and the resulting data is exportable to the billing workflow you already use. That keeps the framework in the role it is suited for, capturing accurate activity, while your billing team keeps control of coding decisions, claim submission and payer rules. Because billing data comes from the same activity that the care team records anyway, there is no separate time-tracking step for staff to remember. The way you want billing data exported and reviewed is scoped during the Fit Assessment and configured alongside your pathways, and you can verify the output end to end during sandbox validation.

Yes. Care coordinators and administrative staff can be assigned tasks alongside clinical roles, because the task layer supports multi-role assignment. Much of care management is coordination rather than clinical work: scheduling follow-ups, confirming transport, collecting documents, making reminder calls. Letting those tasks sit in the same list as the clinical ones means the full picture of a patient's care plan is in one place, and clinicians are not forced to do work that someone else could do. Access is controlled through role-based permissions. Each role can be limited in what it can view or edit on a patient's care plan, so a coordinator can complete and update the tasks assigned to them without being given the same access as a physician. That separation helps with the minimum-necessary principle that HIPAA-covered organizations apply to patient information. Tasks can carry due dates and escalation paths, so if an administrative task is not completed it can escalate to the right person rather than quietly lapsing. Because everyone works from the same patient record and task list in the shared workspace, nurses, coordinators and physicians can see what has already been done, which reduces duplicate outreach to the same patient. The roles in your care team and the permissions each should have are mapped when pathways are configured, starting at the Fit Assessment.

Yes. The Care Management framework and the Remote Patient Monitoring framework share a common data model, so they are designed to work together instead of as two products that need a custom integration between them. When a patient is enrolled in both, RPM alerts can trigger tasks directly inside that patient's care pathway. For example, an out-of-range reading or a missed reading flagged by the monitoring layer can become a task with a due date and an owner in the care team's list, rather than an alert in one system that somebody has to notice and re-enter in another. Because the data model is shared, patient records are not duplicated across the two frameworks, which avoids the reconciliation problems that appear when the same person exists in two systems. Readings captured by RPM can also feed Care Management's risk stratification and task orchestration, so monitoring data influences who the team reaches out to first. Both frameworks follow the same approach to deployment: white-labeled, configurable, HIPAA-compliant and BAA-ready, hosted in your cloud or by Emorphis Health. If you are considering using both, raise it at the Fit Assessment so that pathways, alert thresholds and task rules can be planned together and tested together in sandbox validation.