Hospital-to-post-acute
Discharge to skilled nursing, home health, or rehab with warm handoffs.
Care Coordination Platform
Care Coordination That Closes the Loop Across Settings
We build care coordination platforms that keep patients from falling through the cracks at transitions — real-time ADT event feeds, post-acute handoffs, and closed-loop referrals on a shared FHIR care plan.
HIPAA-ReadyFHIR R4Direct Secure MessagingAudit Logged
Trusted by global innovators
What care coordination software involves
Care coordination platforms manage the handoffs between settings — hospital to skilled nursing facility, ED to primary care, specialist to PCP — where patients most often get lost. The technical core is event-driven: HL7 v2 ADT (admit, discharge, transfer) feeds and FHIR Subscription notifications that tell a care team the moment a patient's status changes, so a post-acute follow-up or transitional care visit actually happens.
Generic messaging and ticketing tools cannot represent a longitudinal care plan shared across organizations, nor can they close a referral loop with a documented outcome. We build coordination as an interoperable layer: shared FHIR CarePlan and CareTeam, Direct Secure Messaging between providers, and closed-loop tracking that proves the handoff completed.
What it is
Keep patients from falling through the cracks
Care coordination platforms connect the people and organizations involved in a patient's care so transitions between settings are planned, tracked, and completed rather than left to chance.
The value is in the seams: the discharge that triggers a follow-up, the referral that closes with an outcome, the post-acute stay that stays visible to the primary team. We build those seams as reliable, event-driven infrastructure.
Architecture
An event-driven coordination layer wired to ADT feeds and shared care plans — so transitions trigger action instead of getting missed.
What We Build Into Care Coordination Platforms
Each capability pairs a transition workflow with the standard that makes the handoff reliable.
Real-Time ADT Event Feeds
HL7 v2 ADT (A01/A03/A04) ingestion and FHIR Subscription notifications trigger care-team action the moment a patient is admitted, discharged, or transferred.
Shared Care Plans Across Settings
FHIR CarePlan and CareTeam resources shared across organizations, so the receiving facility sees the same goals and interventions as the sender.
Direct Secure Messaging
Provider-to-provider Direct messaging and C-CDA transition-of-care summaries so referrals and discharge documents move through a compliant, auditable channel.
Post-Acute Coordination
Track patients into skilled nursing, home health, and rehab with structured handoffs, medication reconciliation, and follow-up task assignment.
Closed-Loop Referral Tracking
Every referral carries a status through completion with a documented outcome written back to the referring provider — no open-ended handoffs.
Risk & Readmission Signals
Utilization patterns and ICD-10 problem lists flag high-readmission-risk patients so transitional care management effort lands where it matters.
Where it fits
Coordination scenarios we support
ED-to-primary-care
Post-ED follow-up routing to close the loop with the PCP.
ACO / value-based networks
Coordination across a risk-bearing provider network.
Transitional care management
TCM programs with structured post-discharge outreach.
Complex case management
Multi-specialist patients with a shared coordinated plan.
Payer-provider collaboration
Health-plan coordinators working shared member panels.
Coordination that closes the loop
Most care gaps happen at transitions. We instrument those moments with real-time feeds and closed-loop tracking.
Real-time
ADT-driven transition alerts via HL7 v2 and FHIR
Closed-loop
Referrals tracked to a documented outcome
Direct
Provider-to-provider secure messaging and C-CDA exchange
Compliance-First Healthcare App Development Services Backed by Global Standards
15-Minute Scoping Call01
HIPAA
Health Insurance Portability and Accountability Act
Protect PHI with privacy-first architecture, encrypted storage and transmission, strict access controls, and traceable audit logs.
02
GDPR
General Data Protection Regulation
Implement lawful consent flows, data minimization, retention controls, and secure processing for sensitive health data.
03
FHIR
Fast Healthcare Interoperability Resources
Enable standardized health data exchange across apps, care teams, and systems through robust FHIR-ready APIs.
04
HL7
Health Level Seven International
Support enterprise-grade interoperability with HL7-based integrations for records, events, and clinical messaging workflows.
05
HITRUST
Health Information Trust Alliance
Align security programs to healthcare-specific control and risk management practices trusted by providers and ecosystem partners.
06
HITECH
Health Information Technology for Economic and Clinical Health Act
Design with breach notification readiness, digital record safeguards, and operational controls that support regulated care programs.
07
SaMD
FDA Software as a Medical Device
Plan software quality, traceability, and documentation pathways for products that may require SaMD review and submission.
08
MDR (EU)
Medical Device Regulation (European Union)
Prepare EU market-ready processes for risk classification, evidence tracking, and lifecycle governance under MDR expectations.
09
SAMHSA
Substance Abuse and Mental Health Services Administration
Apply confidentiality controls and consent-aware sharing models for behavioral and mental health data experiences.
Standards and compliance
Standards behind our coordination builds
HL7FHIRC-CDADirectHIPAA
Our Process
How We Deliver a Care Coordination Build
We treat event feeds, shared care plans, and cross-organization messaging as parallel workstreams from discovery.
1.
Discovery & Transition Mapping
We map your referral network, transition points, and ADT sources, then design the event model and shared care-plan structure.
Event-driven design
2.
Core Build & Feeds
We build ADT ingestion, FHIR Subscription notifications, and the coordination workspace your care teams work from.
Real-time triggers
3.
Interoperability
We wire Direct Secure Messaging, C-CDA exchange, and FHIR care-plan sharing across your partner organizations and EHRs.
Cross-org exchange
4.
Rollout & Loop Closure
Phased go-live with closed-loop referral dashboards, network onboarding, and tuning as transition volume grows.
Measured loops
Featured case study
Read Case StudyLera Health: compliant women's health platform
Related proof of compliant delivery: Lera Health shows how we build privacy-first, longitudinal care experiences on a HIPAA-ready foundation. It is not a care-coordination product, but the same interoperability and data-layer discipline underpins our coordination work.
Why Partner With Us
15-Minute Scoping CallWhy teams choose Agnotic for care coordination
Coordination lives or dies on interoperability. We have the standards depth to make cross-organization handoffs reliable.
Interoperability-First
ADT feeds, Direct Secure Messaging, and C-CDA exchange are engineered as core infrastructure, not bolted on late.
Cross-Setting Workflow Depth
We design for how acute, post-acute, and ambulatory teams actually hand off, so transitions complete instead of stalling.
Closed-Loop by Default
Every referral and transition carries a status to completion with a documented outcome — accountability is built in.
Compliant Data Handling
PHI moves through auditable, encrypted channels across organizations, with consent and access controls at the data layer.
Our relevant experience
Transitions that complete — because the handoff is engineered.
Frequently Asked Questions
Cost scales with the number of ADT sources and partner organizations you connect. A coordination workspace with ADT feeds, shared care plans, and one EHR integration is typically a three-to-five-month build; multi-organization networks with Direct messaging and C-CDA exchange scale from there. We scope against your network before quoting.
Ready to close the loop on care transitions?
Tell us about your referral network and transition points. We'll return a phased plan with ADT feeds, shared care plans, and closed-loop tracking.
contact@agnotic.com
Partnerships
contact@agnotic.com