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Care Coordination

Care Coordination Software to Connect Every Patient, Program, and Provider

Vervelo unifies all VBC programs into a single care coordination workflow — risk stratification, outreach, referrals, and care gap closure.

Care Coordination Dashboard

Measurable Outcomes for Coordinated Value-Based Care Programs

Care coordination is what separates reactive sick care from proactive value-based care. Practices that systematically coordinate across programs see dramatically better outcomes — and significantly higher per-patient revenue.

Hospitalizations

28%

Reduction in Preventable Hospital Admissions with Active Coordination

Care Gap Closure

43%

Of Open Care Gaps Closed Within 90 Days of Program Enrollment

Patient Engagement

67%

Improvement in Patient Engagement Rates vs. Uncoordinated Practices

Revenue Uplift

2.4×

Average Revenue Per Patient When CCM + Coordination Programs Are Bundled

Features

A Comprehensive Feature Pack for Your Care Coordination Platform

From population risk stratification and care gap dashboards to automated patient outreach and closed-loop referral tracking, Vervelo gives care teams everything they need to coordinate care across all VBC programs in one place.

Care Coordination

Population Risk Stratification & Care Gap Dashboard
Risk Stratification Dashboard

Vervelo's risk engine automatically stratifies your entire patient panel by complexity and surfaces open care gaps across HEDIS measures and program eligibility criteria — so every coordinator knows exactly where to focus.

Care Coordination

Multi-Channel Patient Outreach & Engagement Engine
Outreach Engine

Automated SMS, email, and voice outreach sequences keep patients engaged across all programs. Consent tracking, communication logs, and escalation rules are all built in.

Care Coordination

Closed-Loop Referral & Specialist Coordination
Referral Management

Track referrals from order to completion. Share care summaries securely with specialists and automatically flag unresolved referrals before they become care gaps.

Care Coordination

Unified Care Plans Across All VBC Programs
Unified Care Plans

Build a single coordinated care plan spanning CCM, RPM, BHI, and more. Team role assignments and real-time update alerts ensure nothing falls through the cracks.

Why Vervelo for Care Coordination

Built for multi-program VBC practices that need one platform to coordinate care across every patient, every program, and every provider.

HIPAA Compliant
HIPAA Compliant

End-to-end encryption, role-based access controls, and automated audit logs keep your coordination data secure and CMS audit-ready.

Population Health Tools
Population Health Tools

Risk stratification, care gap analysis, and program eligibility matching across your entire patient panel — not just enrolled patients.

EHR Compatible
EHR Compatible

Bi-directional integrations with Epic, Athenahealth, eClinicalWorks, and 50+ other EHR systems. No duplicate charting.

Scales to Any Practice
Scales to Any Practice

From a single-provider clinic coordinating 200 patients to a multi-site group managing 10,000 — the same platform grows with you.

Primary Aims of Vervelo Care Coordination

Every care coordination capability in Vervelo's platform is designed to advance one or more of these core outcomes.

01
Reduce Preventable Hospitalizations

Proactive outreach, medication adherence support, and early warning signals from RPM reduce avoidable admissions — the highest-cost event in any value-based contract.

02
Close Care Gaps Systematically

A structured, dashboard-driven approach to closing HEDIS measures, overdue screenings, and missing interventions — not a periodic chart review sprint.

03
Coordinate Across Every Specialist

Closed-loop referral tracking ensures every specialist recommendation makes it back into the care plan — and that the patient actually follows through.

04
Improve Patient Activation

Multi-channel outreach and a clear, shared care plan increase the percentage of patients who actively engage with their own health between visits.

05
Enable Population Health Management

Move from managing individual patients reactively to managing your entire attributed population proactively — segmented by risk, program, and care gap status.

06
Maximize VBC Program Revenue

Systematic coordination directly increases billing opportunities across CCM, PCM, RPM, BHI, and AWV by ensuring eligible patients are enrolled and active.

120+ Healthcare Organizations Trust Vervelo

Across CCM, PCM, RPM, BHI, AWV, TCM, and APCM programs

Get Started

Care Coordination in Practice

Real results from practices using Vervelo's coordinated care platform.

CarePlus Telehealth
Care Coordination
CarePlus Telehealth

28% reduction in hospital admissions after deploying Vervelo's population health dashboard across 1,200 CCM patients.

Grandview Hospital Medical Group
Care Gap Closure
Grandview Hospital Medical Group

Closed 41% of open HEDIS care gaps within 60 days using Vervelo's automated outreach and coordinator worklist.

HealthBridge Primary Care
Multi-Program Enrollment
HealthBridge Primary Care

Enrolled 340 patients across CCM + RPM + BHI simultaneously using Vervelo's program eligibility matching engine.

Built to Meet Healthcare's Highest Compliance Standards

HIPAA Compliant GDPR HL7 FHIR SOC 2 Type II Vervelo Certified
Vervelo

Ready to Coordinate Care Across Every Program?

Talk to a Vervelo care coordination specialist. We'll walk through your current program mix, identify coordination gaps, and show you exactly how the platform works for practices like yours.

Population risk stratification & care gap dashboard demo

Revenue analysis across all enrolled VBC programs

EHR integration assessment for your specific system

Get a Free Coordination Assessment

Frequently Asked Questions

Common questions about care coordination with Vervelo.

How is care coordination different from CCM or PCM? +
CCM and PCM are specific CMS-reimbursed programs with defined CPT codes and time requirements. Care coordination is the operational infrastructure that makes all VBC programs work — it encompasses patient outreach, referral management, care plan oversight, and program enrollment across your entire panel. Vervelo's platform supports both: the specific program billing workflows AND the broader coordination layer that connects them.
Can I bill for care coordination separately? +
Care coordination activities are often captured within CCM (99490), Complex CCM (99487/99489), TCM (99495/99496), and APCM (G4001–G4003) billing codes. Vervelo's platform helps you document coordination time accurately within these billable programs — and surfaces additional program eligibility you may be missing, increasing your total per-patient revenue.
What staff can perform care coordination activities? +
CMS allows licensed clinical staff working under a physician's supervision to perform care coordination and document billable time. This includes RNs, LPNs, MAs, social workers, and care managers. Vervelo's platform assigns tasks by role and tracks time per staff member — supporting both direct billing and audit documentation.
Does Vervelo integrate with our EHR for care plan data? +
Yes. Vervelo integrates bi-directionally with Epic, Athenahealth, eClinicalWorks, Greenway, NextGen, and 50+ other EHR systems. Care plans, encounter notes, diagnoses, and medication lists sync in real time — so coordinators work from current data without duplicate charting.
How quickly can we get the care coordination platform operational? +
Most practices are fully operational within 2–3 weeks. Week one covers EHR integration and patient panel import. Week two covers coordinator training and care gap dashboard setup. By week three, your team is working live worklists and your risk stratification model is calibrated to your patient population.