Abstract: Methods, systems, and computer-readable media are provided for aligning a patient who is determined to be eligible for care management services with a care manager. Patient health data is received and is used to generate a patient profile for the patient. The patient profile comprises, for example, demographic information, geographic location, clinical characteristics, patient preferences, a patient need level, a category to which the patient is assigned, and a priority level associated with the patient. A set of characteristics associated with a group of care managers is accessed where the set of characteristics include clinical expertise of the care manager, geographic location of the care manager, workload capacity of the care manager, and the like. Using the patient profile and the set of characteristics associated with the group of care managers, the patient is aligned with a care manager well-suited to help the patient achieve care management goals.

Abstract: Methods, systems, and computer-readable media are provided for automatically generating outreach events for a care management service. Patient health data is received and processed to determine that a patient is eligible for care management services. Upon determining that the patient is eligible for care management services, a welcome-to-service template is selected, populated with patient-specific information, and communicated to the patient. The patient's health data is monitored to determine if there has been a change in care management status for the patient. Upon detecting a change in status, an appropriate template is selected, populated with patient-specific information, and communicated to the patient and/or a care team caring for the patient.

Abstract: Methods, systems, and computer-readable media are provided for automatically generating outreach events for a care management service. Patient health data is received and processed to determine that a patient is eligible for care management services. Upon determining that the patient is eligible for care management services, a welcome-to-service template is selected, populated with patient-specific information, and communicated to the patient. The patient's health data is monitored to determine if there has been a change in care management status for the patient. Upon detecting a change in status, an appropriate template is selected, populated with patient-specific information, and communicated to the patient and/or a care team caring for the patient.

Abstract: Methods, systems, and computer-readable media are provided for aligning a patient who is determined to be eligible for care management services with a care manager. Patient health data is received and is used to generate a patient profile for the patient. The patient profile comprises, for example, demographic information, geographic location, clinical characteristics, patient preferences, a patient need level, a category to which the patient is assigned, and a priority level associated with the patient. A set of characteristics associated with a group of care managers is accessed where the set of characteristics include clinical expertise of the care manager, geographic location of the care manager, workload capacity of the care manager, and the like. Using the patient profile and the set of characteristics associated with the group of care managers, the patient is aligned with a care manager well-suited to help the patient achieve care management goals.

Abstract: The present invention is directed to, among other things, providing a personalized patient care plan that is customizable based on a healthcare role associated with a user and that is shared among a plurality of healthcare providers associated with a plurality of healthcare venues. In one aspect, healthcare data associated with the patient is received from the plurality of healthcare providers associated with the plurality of healthcare venues. Based on a healthcare role associated with a user, a set of the healthcare data that is relevant to the user may be extracted. The set of the healthcare data may be populated as a set of care plan items in the personalized care plan for the patient. This personalized care plan may then be presented to the user.