For Care Management & ACOs
The home visit is where care plans get met
Care management teams set the strategy. The home visit is where the strategy turns into outcomes. Capillary Health is the dispatch and routing layer that connects your risk-stratified panel to a clinician on a porch with structured documentation flowing back.
Three workflows ACOs and care management teams plug into
Rising-risk panel intervention
A care manager identifies a panel of patients trending toward avoidable utilization. The intervention is a home visit, a CHW check-in, or a medication reconciliation. Capillary Health dispatches and routes those visits, captures the outcomes, and feeds them back to your population health platform.
Post-acute transition coverage
Patients in the 7- and 30-day post-discharge window are the highest-risk slice of any panel. We route the post-discharge home visits, the follow-up phone calls, and the medication reconciliation visits as a coordinated bundle, with structured documentation back to the index discharge.
SDOH-driven outreach at scale
Population-level SDOH screening surfaces patients who need food, housing, transportation, or behavioral health connections. We route the community health worker visits and warm handoffs that turn a screen into a service connection, with documentation that closes the loop in your registry.
Why structured outcome data matters
Care management programs live or die on attribution. If a home visit was supposed to prevent a readmission and you cannot show, in your registry, which patients got the visit, when, and what happened, you cannot make the value-based case.
The default state of home-based care is the opposite of structured. Visits get logged in a case management system that does not exchange data with your population health stack. Outcomes live in free text. The link between the rising-risk flag and the dispatched intervention is a phone call.
Capillary Health treats every dispatched visit as a structured event linked to its index reason. Encounter, Procedure, and Observation resources flow back to your platform. The ACO reporting story writes itself because the data is already structured.
For programs operating across multiple referral sources (ED, primary care, hospital discharge, payer outreach), the same closed-loop architecture applies. The standards underlying it (USCDI, the Gravity Project, HL7 eReferral) are walked through in the closed-loop referral anatomy resource.
What integrates with your stack
- CSV / XLSX upload of risk-stratified panels and outreach lists
- FHIR-based ingestion of ServiceRequest and Patient resources where the receiving system supports it
- Outbound structured outcome data (Encounter, Procedure, Observation) for ingestion by your population health platform
- Care plan adherence tracking tied to specific dispatched visits
- ACO and value-based contract reporting workflows
- BAA-compliant data exchange with audit logging
Further reading
Anatomy of a closed-loop referral
USCDI, Gravity Project, eReferral standards, and where most loops break.
SDOH Z-codes for home-care referrals
Documentation reference your panel reviews can ride on.
For Emergency Medicine
If a meaningful share of your panel touches the ED, where the upstream loop starts.
Connect your panel to a porch
Tell us how your population health stack is structured and we will walk through what it looks like to dispatch home visits against it.