For Medicare Advantage plans, IPAs and MSOs
A fully managed, nurse-led care team on our own platform. We watch member readings every day and act early, so a rising blood pressure or glucose reading becomes a nurse call, not an emergency visit or a readmission.
Patient engagement
Patient retention
Program completion
Across OnCare360 fully managed programs, 2026. Engagement: enrolled patients with vitals received and a live care coordinator call that month, covering medications, nutrition and self-care education.
One accountable team for the work between visits: outreach, monitoring, education and follow-up, reported back to you against the measures you are paid on.
Close care gaps
Your gap lists become nurse worklists, from annual wellness visits to overdue screenings. Closure status flows back to you, member by member.
Catch problems early
Home readings are reviewed every day. Out-of-range values trigger nurse outreach and escalation to the physician before they become an emergency visit.
Follow up after discharge
Connected to your admission and discharge notifications, our team calls after a hospital stay: medication reconciliation, follow-up appointments and warning signs, to help keep members from being readmitted.
Align to Stars and HEDIS
Program activity mapped to the quality measures your ratings depend on: blood pressure control, diabetes control, medication adherence and transitions of care.
Stratify and manage risk
Members tiered by risk, with care intensity matched to need and a step down once they are controlled.
A care plan for every member
Individualized care plans built from each member’s conditions, medications, goals and social needs such as food, transportation and housing, updated as their needs change.
Improve member experience
The same multilingual care team every month, with satisfaction measured and reported back to you, supporting the member experience side of your Star ratings.
Works with your network
We keep members connected to their own primary care physicians and send updates back, so care stays with your providers, not around them.
Clinical oversight, as an option
NP-led oversight and physician escalation protocols where you need a clinical home for the program.
1
Identify
We start from your claims data and gap lists to find the members who need support.
2
Stratify
Members are tiered by risk so care intensity matches each member’s need.
3
Engage
Nurse-led outreach and AI-assisted monitoring, with a care coordinator always a call away.
4
Report
Results on a set schedule, measured against a baseline we agree on up front.
You see what is happening with your members every month, and what changed every quarter and every year.
Monthly
Enrollment, engagement, readings and escalations
Quarterly
Progress against care gaps and quality measures
Every six months
Outcome trends against baseline
Annually
Full outcome report: clinical, utilization and member satisfaction
Results from selected programs
Average systolic blood pressure in a cardiovascular specialty practice, from 146/89 to 128/76, falling every quarter for 15 months.
Average systolic every month in a multi-provider cardiology practice in value-based care programs, with 82% of monitored patients still engaged.
A cardiology group’s monitored panel grew sixfold in nine months while average systolic stayed under 135 every month.
Population averages from OnCare360 platform data, de-identified and aggregated. No comparison group. Practices are described, not named.
Built to lower total cost of care
Most avoidable cost starts between visits: an uncontrolled reading that turns into an emergency visit, a missed follow-up that turns into a readmission. That is where our team works, and we measure the impact on cost with you against your claims baseline.
Diabetes
Hypertension
Heart failure
CKD
Obesity
COPD
Behavioral health
Fully managed: nurses, platform, devices and reporting
Multi-state delivery, with licensure matched to your footprint
SOC 2 Type II and HIPAA compliant
Live in 2 to 4 weeks, from claims or EHR data
Share a de-identified summary of your membership by condition, risk score and state. We will show how we would stratify it and what your reporting would look like.
