Care Coordination That Connects the Full Patient Journey
Healthfully gives care teams the tools to manage care plans, track referrals, address social needs, and coordinate transitions of care — connected to the patient-facing scheduling and engagement workflows that make coordination actionable.
Care Coordination Fails When the Tools Are Disconnected
Most care coordination programs run into the same problem: the tools that care managers use to track patients are completely disconnected from the digital channels through which patients actually engage with their care. Care plans exist in one system. Patient messaging is in another. Referral tracking is in a spreadsheet. SDoH screening results are collected on paper. When the coordination infrastructure does not connect to patient-facing workflows, care plans stay internal documents rather than active guides to patient behavior.
Care Plans That Don't Connect to Patients
A care plan that only care team members can see is half a care plan. When patients cannot access their plan, receive prompts based on it, or communicate through it, coordination stays internal.
Referral Leakage With No Visibility
Referred patients who receive a phone number and are expected to schedule independently often do not. Without referral tracking, organizations do not know how many patients are falling out of the care network.
SDoH Data Collected but Not Acted On
Screening for social determinants of health without connecting results to case management, community resource matching, and follow-up workflows collects data without creating impact.
Care Plans, Referrals, and Patient Engagement in One Connected Platform
Healthfully connects the internal tools care teams use — care plans, assignments, referral management, patient queues, SDoH case management — with the patient-facing tools that make coordination effective: scheduling, secure messaging, telehealth, and digital forms. When the coordination infrastructure and the patient engagement layer are the same platform, care managers can act on clinical triggers instead of just documenting them.
Care Plans and Assignments
Build configurable care plans with goals, to-dos, assessments, and clinical milestones. Assign tasks to care team members. Track status and outcomes over time across a patient population or specific care program.
Referral Management
Send referrals digitally and track completion from the referring provider to the receiving provider to the patient's confirmed appointment. Identify where referral patients drop off and intervene before they leave the care network.
SDoH Screening and Case Management
Screen patients for social determinants of health, match identified needs to community resources, and manage ongoing case notes, assignments, and follow-up — within the same platform used for clinical care coordination.
Transitions of Care
Manage care transitions across settings — hospital to home, acute to post-acute, specialist to primary care — with structured handoff workflows, follow-up prompts, and patient engagement tools that keep patients connected through the transition.
Case Study:
Iowa State University — Virtual Visits for 30,000+ Students
Iowa State University's Health Services implemented Healthfully to streamline registration, scheduling, and virtual visits for over 30,000 students — with seamless NextGen EMR integration and high adoption from students and staff.
Streamlined registration, scheduling, and virtual visits across the entire student health service
Branded platform deployed for 30,000+ students across the university campus
Seamless NextGen EMR integration with high satisfaction from students and health services staff
Coordination Infrastructure Connected to Patient Engagement
Care plans, referrals, and SDoH case management in one platform — not across separate disconnected systems
Patient-facing scheduling, messaging, and telehealth connected to the coordination workflow
Population health dashboards give care leaders visibility into program performance and care gaps
Configurable for ACO programs, value-based care contracts, and specialty care coordination programs
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Ready to Connect Your Care Coordination Workflow?
Healthfully connects booking, intake, and eligibility in one workflow — so patients arrive prepared and staff work from complete information every time.