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Measure and Improve Health Outcomes

Better coordinate care, improve health outcomes and reduce fragmentation in care delivery by coordinating care across healthcare providers and settings.

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Delivering Excellence in

Patient-Centered and

Accountable Care

At Fonemed, our goal is to assist accountable care organizations and healthcare providers in delivering excellence in patient-centered, accountable care. We act as a strategic partner for our healthcare clients and equip them with the knowledge, personnel support and software to better coordinate their care processes through data integration, workflow automation and integral communication features.

Our unique Population Health Management Platform squarely addresses the business objectives of ACOs through its ability to improve care coordination, place an emphasis on preventative care, patient engagement and ensure patients have greater access to healthcare providers. Fonemed’s PHM software enables our clients to provide cost effective member/patient management 24 hours a day, seven days a week with biometric monitoring available.

We know that delivering high quality care when and where it is needed most is critical to those responsible for Accountable Care. Naturally, we’ve created our software with these priorities in mind in order to deliver the value and benefits that ACOs expect.

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Conduct Assessments and Perform Risk Stratification

Fonemed’s Population Health Management Platform offers Primary Assessments that are completely configurable and can be easily adapted to organizational requirements. These assessments are a powerful tool that can be used to identify current health issues, and patient needs for support and education, reveal any gaps in care, and populate a plan of care. By using these evidence-based health risk assessments, clinicians can derive the complete state of health for a patient.

A simple, intuitive interface guides the clinician through the process of collecting the patient’s data efficiently, resulting in a patient-centric profile and the generation of the critical baseline measurements to be used in the patient’s plan of care. The quantifiable outcomes assessments data can then be used to identify subsets of patients who drive cost, utilization and resource consumption.

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Develop and Manage Your Patient’s Plan of Care

The plan of care provides a patient a path to positive health outcomes and helps them reach their goals with support from a clinical care team. It provides the necessary foundation for teaching patients how to better understand and manage their condition(s) so that they may improve or control its health impact. The plan of care is generated automatically after conducting the primary assessment and is immediately available in the system’s user interface for final approval by the medical provider.

Care Delivery Management and Oversight

Once the member-centric profile is created, the care team can utilize the system assessment dashboard to monitor their patient’s data and track encounters throughout the continuum of care. Using robust analytics, care coordinators, nurse navigators and other clinicians can continuously monitor patients and populations, identify trends and make adjustments to care plans or perform interventions when necessary. Conducting regular, periodic assessments are easy using our software and it can greatly assist providers in engaging the patient in a relationship that supports positive health outcomes.

Care Coordination Management

Fonemed’s care coordination management and oversight software features deliver the following benefits to healthcare organizations:



The ability to identify, treat and minimize symptoms


Close gaps in care and ensure early interventions


Coordinate ongoing or periodic assessments that involve the appropriate specialists


Prevent complications that could lead to readmission

Cost Containment

Reduce ED visits


Improve medication/treatment compliance

Quality of Life

Optimize patient’s health and quality of life


Reduce avoidable healthcare utilization

Care Transition

Manage care transitions as patients move through the health system and continuum of care


Decrease hospital admissions by identifying problems before they require an in-patient stay


Process management helps to ensure staff productivity and competence

Coordinate Care Team Activities

Reduce fragmentation in care delivery by coordinating care across healthcare providers and settings. With the Fonemed health management platform healthcare, providers can develop and manage their populations and communicate effectively with them in a team-based environment.

Build Your Team

Designate your care team based on your organization’s unique requirements to share data, clinical insights and more easily coordinate care than ever before. Assemble your team across the continuum of care, including specialty providers such as behavioral health, clinical pharmacy, palliative care, motivational coaches and other healthcare professionals. Complete with roles and permissions that govern access, Fonemed’s software enables providers to access and view a patient’s overall project plan, next milestones, and team member responsibilities anytime, anywhere.

Engage Patients and Their Care Team with Greater Connectivity

Care team members and patients can stay connected through instant and secure communications features. Our Population Health Management Platform provides Physicians, Care Coordinators, nursing staff and other Accountable Care providers the ability to interact with their patients effectively and efficiently through a variety of available tools. Options include telephonic, video chat, and secure application messaging support. Notably, each of these modalities can be monitored by clinical staff to determine patient needs and promote engagement. Improved connectivity affords healthcare organizations the ability to ensure more patient touches without increasing staff levels. Our software also integrates with telephony and interactive voice response systems, providing even greater operational efficiency.

Timely Alerts and Notifications

Manage urgent and emerging needs, and address discrepancies through timely alerts that help ensure that care delivery is on track. Alerts and notifications offer a critical communication capability that can notify care team members if inconsistencies or omissions are discovered in care requirements. Alerts are entirely customizable and can be prompted by patients, remote monitoring devices, or care givers.

Physician Portal Access

The Fonemed Population Health Management System (PHMS) also offers a valuable interface for physicians to access their patients’ information and coordinate care. Physicians can easily view any patient profile, approve care plans and receive notifications from patient monitoring alerts.

Physicians can develop a deeper understanding of their patients’ by accessing rich-data patient profiles that contain information such as:

  • Medical history and patient demographics
  • Culture and home environment
  • Weight, diet and nutrition information
  • Lifestyle and habits
  • Data supplied by remote monitoring devices

Combined with other information provided by the patient, home-health nurses, or other caregivers outside of the care facility, physicians are equipped to make stronger health care decisions on behalf of their patients.

Key features of the physician portal include:

  • Browse and review patients information and reports
  • Announcements
  • Tasks/Alerts
  • Library
  • Message both patient and other care providers
Patient Portal Access

Our patient portal offers the ability for a patient or designated caregiver to monitor not only their own data, but data submitted by others involved in their care as well. Patients are able to view and comment on their complete care plan via the patient portal including status, recommendations, associated goals and interventions. Patient portals enhance patient engagement and empower patients to play a greater role in their own health.

To help ensure more accountable care, members can also provide feedback about the quality of care they have received and the effectiveness of health education resources directly from the patient portal.

Key features of the patient portal include:

  • Calendar and Upcoming Appointments
  • Medications
  • Messages
  • Care Plan
  • Resource Library
Beyond Encounter Analytics

Quality data reporting and collection support quality measurement. Fonemed’s PHMS offers flexible, HIPPA compliant reporting options for both quality and cost. Our reporting features help your organization stay patient-focused, improve care processes, promote evidence based medicine and enhance patient engagement.

Unique to Fonemed’s PHMS is the software’s comprehensive auditing capabilities that vastly extend the possibilities for reporting. Our PHMS inherently tracks and captures all events and interactions performed, making all information fully auditable and available for reporting purposes.

Supported by enterprise-class searching and filtering features, clients can specify any data elements they wish to make available in simple, usable reports that are invaluable for ensuring performance standards are being met.

Administrative, quality management, patient encounter reports and more, can be produced on-demand or scheduled via automated delivery in any number of common business formats (i.e, .docx, .xls, .pdf, .ppt,).

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