Product
Monitor.Care is multi-tenant care-coordination software for clinics and care management teams. Track a patient from hospital admission through 30 days post-discharge so they stay on the path home — not back in the ED.
Care journeys
Inpatient pathway
- Admission detected
- Notify PCP / MD of admit
- In-hospital coordination & discharge planning
- Discharge
- Day-1 TCM outreach
- TCM appointment (≤7 days ideal)
- Visit completed + med rec
- 30-day monitoring complete
Outpatient / post-DC TCM
- Discharged to Home / SNF / IPR-LTAC / Hospice
- Day-1 TCM call
- Day-2 second attempt if needed
- TCM appointment set
- Patient attended
- Med rec completed
- 30-day window closed
Daily workspace
Dashboard
KPI cards and charts so coordinators and leadership see workload and outcomes at a glance.
Tasks
Open work queue — what is needed next for each patient, filterable and completable in place.
Patients & cases
One open case per patient. Shared identity (name, DOB, payer, PCP) across inpatient and outpatient journeys.
Notes & audit
Every step is documented with user + timestamp. Full audit log with before/after values.
Reports
Charts with drill-down and Excel export for hospital, payer, and pathway views.
Import
Spreadsheet import for inpatient/outpatient panels; FHIR connector stub for when your EHR is ready.
Roles
Admin
Platform/tenant admin, customers, data sources, logs, full access.
Coordinator
Patients, cases, tasks, and notes — the day-to-day care team role.
Reporting
Dashboards and export without full clinical write access.
Read only
View patients, cases, and reports for oversight.