Abstract: The present disclosure is directed to a system for coordinating medical care including a hub computing device which operates as a hub portal comprising a processor and a display, a data collection component, wherein the data collection component allows for a listing of clients or patients including client information and client personas, a listing of medical, health and social service providers to be uploaded onto the hub portal by an associated hub user, and for recording of a patient's community health records with various service providers through use of the system, a graphical user interface, wherein the set of instructions encoded on the non-transitory computer-readable storage medium include the steps of analyzing data collected by the data collection component, analyzing, in real-time, gaps in patient care, and providing predictive activity suggestions, and a neural network that machine learns from data to provide the predictive activity suggestions.

Abstract: A system and method for creating efficient and cost saving care plans for clients through the use of artificial intelligence and passing those savings on to care providers and healthcare services and programs to further increase efficiency and greater profitability while significantly reducing overall Medicare and Medicaid expenses to governments.

Abstract: The present disclosure is directed to a system for coordinating medical care including a hub computing device which operates as a hub portal comprising a processor and a display, a data collection component, wherein the data collection component allows for a listing of clients or patients including client information and client personas, a listing of medical, health and social service providers to be uploaded onto the hub portal by an associated hub user, and for recording of a patient's community health records with various service providers through use of the system, a graphical user interface, wherein the set of instructions encoded on the non-transitory computer-readable storage medium include the steps of analyzing data collected by the data collection component, analyzing, in real-time, gaps in patient care, and providing predictive activity suggestions, and a neural network that machine learns from data to provide the predictive activity suggestions.

Abstract: The present disclosure is directed to a computerized method, system and software application for coordinating medical care through a Pathways Community Hub (HUB). A Pathways Community Hub is a network of care coordination agencies which focuses its mission towards reaching individuals within the community having the greatest risk-factors through the deployment of service providers such as community care coordinators. The Pathways Community Hub finds at-risk individuals in need of medical, health-related or social services, treats identified risk factors and measures a patient's risk status over time. The goal of the Pathways Community Hub is to achieve a reduction of risk among patients through open communication and collaboration among service providers including medical service providers and community-based organizations and to reduce the overall cost of medical, health-related and social services over time within a region.

Abstract: The present disclosure is directed to a computerized method, system and software application for coordinating medical care through a Pathways Community Hub (HUB). A Pathways Community Hub is a network of care coordination agencies which focuses its mission towards reaching individuals within the community having the greatest risk-factors through the deployment of service providers such as community care coordinators. The Pathways Community Hub finds at-risk individuals in need of medical, health-related or social services, treats identified risk factors and measures a patient's risk status over time. The goal of the Pathways Community Hub is to achieve a reduction of risk among patients through open communication and collaboration among service providers including medical service providers and community-based organizations and to reduce the overall cost of medical, health-related and social services over time within a region.

Abstract: The present disclosure is directed to a computerized method, system and software application for coordinating medical care through a Pathways Community Hub (HUB). A Pathways Community Hub is a network of care coordination agencies which focuses its mission towards reaching individuals within the community having the greatest risk-factors through the deployment of service providers such as community care coordinators. The Pathways Community Hub finds at-risk individuals in need of medical, health-related or social services, treats identified risk factors and measures a patient's risk status over time. The goal of the Pathways Community Hub is to achieve a reduction of risk among patients through open communication and collaboration among service providers including medical service providers and community-based organizations and to reduce the overall cost of medical, health-related and social services over time within a region.