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AccessMeCare™ · Stakeholder Solutions

Built for Every Point in the Care Journey.

From frontline clinics to agencies, AccessMeCare™ is purpose-built to help every stakeholder in the healthcare ecosystem improve access, reduce costs, and deliver better outcomes for the people they serve.

Home/Who We Help
Our Guiding Principle

The individual is always at the center.

Every stakeholder in the care ecosystem — clinics, hospitals, payors, agencies — serves the same person. AccessMeCare™ is designed from that truth outward: a health-promoting ecosystem that wraps around the individual, connecting every resource they need across every domain of their life.

This isn't care coordination as a workflow tool. It's care coordination as a moral commitment — to meeting people where they are, navigating their full complexity, and never letting a fragmented system become a barrier to a healthier life.

Whole-Person

Health, behavioral health, and social needs addressed as one continuum — not separate silos

Community-Rooted

Built on CBPR principles, reflecting the lived experience of the populations we serve

Equity-Centered

Designed to reduce disparities in access, outcomes, and dignity of care for vulnerable populations

The Individual
Human Center Care
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Discover
📋
Assess
Match
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Access
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Coordinate
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Track
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Primary Care
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Hospitals & Systems
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Behavioral Health
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SUD & Recovery
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Community Services
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Government & Public Health
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Payors
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Crisis Response
AccessMeCare™ coordinates every connection
Who We Serve

Built for every stakeholder in the care ecosystem.

From clinics to agencies, AccessMeCare™ helps every organization improve access, reduce costs, and deliver better outcomes.

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Clinics
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Hospitals
Learn More →
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Health Systems
Learn More →
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Payors
Learn More →
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Agencies
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Stakeholder 01
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Clinics, FQHCs & CCBHCs

Community-based clinics, FQHCs, and CCBHCs navigate four persistent challenges every day—fragmented referrals, administrative burden, disengaged patients, and unreimbursed work. AccessMeCare™ brings it all together by increasing access to clinical services by up to 180% and streamlines intake and coordination. It transforms every human centered interaction into a meaningful outcome for clients so your team can focus on care, not complexity. AccessMeCare™ enables community-based providers to deliver whole-person care at scale — without adding headcount.

  • Streamline service documentation and reporting
  • Builds trusted community networks to drive higher patient engagement and improve utilization rates at your FQHC/CHC
  • Acts as a single point of trust to strengthen collaboration between health, behavioral, and social service providers
  • Seamlessly integrates primary care, behavioral health, and prevention programs into one easy-to-use platform
  • Equips Community Health Workers, Peer Support Specialists, and care teams with better tools to serve clients without adding staff or complexity
54–56%

Of CHCs cite insufficient staffing or availability of community-based organizations as major obstacles to effective care coordination for social needs.

70%

Of CHCs reported critical workforce shortages while heavy administrative loads directly decrease available patient care hours contributing to provider frustration, burnout, and attrition.

Key Capabilities · Clinics
01
Community Health Worker & Peer Support SuiteMobile-first CHW tools with task management, client tracking, and supervisor dashboards built in
02
SUD & MOUD CoordinationEnd-to-end opioid use disorder navigation — from screening to treatment engagement to sustained recovery support
03
Closed-Loop Referral NetworkBi-directional referrals with status tracking across 250+ community partner organizations
04
CCBHC Compliance EngineAutomates qualifying service tracking, outcome measure reporting, and prospective payment system documentation
CCBHCFQHCMOUD / OUD42 CFR Part 2CHW WorkflowsSDOH ScreeningSAMHSA
"Up to 50–70% of patients referred to behavioral health services never complete treatment, reflecting significant access and follow-through barriers."

Substance Abuse and Mental Health Services Administration. (2023). Key substance use and health Indicators in the United States. · Reference

Where AccessMeCare™ Intervenes
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Connected Care Navigation
Proactively navigate ambulatory care patients to appropriate community-based care before the next visit
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Discharge Planning
Automated referral and follow-up workflows activate at the point of discharge order
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High-Quality Transitions
Connect individuals to the right care across 20+ conditions, 15+ social needs, and 11 care barriers
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No Integration Required
AccessMeCare™ translates costly, labor-intensive processes into streamlined service without EHR integration
17.1 Million

Primary care treatable ED visits occur annually nationwide

$32 Billion

In excess costs to the U.S. healthcare system each year

HL7 / FHIRHIE CompatibleCMS Quality MeasuresCare TransitionsVBCPopulation Health
Stakeholder 02
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Hospitals & Health Networks

AccessMeCare™ helps hospitals reduce patient write-offs and readmission penalties while improving outcomes and efficiency by seamlessly connecting inpatient episodes to community-based services that drive sustainable recovery. By addressing patients' non-medical barriers to care, AccessMeCare™ increases patient access to the most appropriate centers of care, aligning medical services with prevention and support programs to lower uncompensated care costs as rising uncompensated care is expected to pressure hospitals and meet Community Benefit requirements.

  • Reduce Avoidable Readmissions:AccessMeCare coordinates care across community partners, reducing readmissions by addressing community and patient-level factors that drive repeat hospitalizations.
  • Decrease ED Utilization:Proactively navigate patients to lower-acuity settings, cutting avoidable Emergency Department visits by up to 20% and easing overcrowding, especially among vulnerable and Medicaid populations.
  • Lower Patient Write-Offs:Connects uninsured and underinsured patients to the most appropriate care providers and social services, significantly decreasing uncompensated care costs and bad debt while improving financial performance.
  • Improve CMS Quality Scores:Enhance value-based purchasing performance and CMS quality metrics by increasing appropriate care access, preventive services participation, and overall population health outcomes.
  • Extend Care Management Reach:Integrates community-based care workers into the care continuum without expanding internal FTEs, reducing case worker burden and increasing targeted care-seeking behavior by up to 180%.
Stakeholder 03
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Health Systems & Integrated Networks

Reduce financial strain, workforce burden, and access barriers by guiding patients to the right care — driving better outcomes and sustainable system performance. AccessMeCare™ becomes the connective tissue across your entire continuum.

  • Unify care coordination across multiple facilities, service lines, and community partners
  • Deploy population health management at scale with digital care navigation and behavioral health integration
  • Support rural access strategies with technology designed for underserved communities
  • Reduce workforce burnout through intelligent task routing and automated care workflows
  • Compete for and retain value-based care contracts with measurable outcome data
38%

Of referrals never result in a completed appointment, with most falling through the cracks between the referring office and the specialist scheduler.

14.6%

Of hospital discharges result in 30-day all-cause readmissions, creating major HRRP penalty exposure and care continuity risks that automated 72-hour outreach can mitigate at scale.

"The ability for someone to live a healthy, self-sufficient life is frequently driven by a complex interplay among providers, programs, and the people those programs are intended to serve. AccessMeCare™ was built to overcome that complexity."

Heudia Health · Platform Philosophy
Enterprise Capabilities
01
Patient Leakage Tracking & Network RetentionIdentifies patients at risk of seeking care outside the IDN's network — by monitoring referral completion and appointment follow-through — protecting both revenue and care continuity
02
Automated Post-Discharge Outreach & Care Transition WorkflowsEliminates manual follow-up calls that consume care manager capacity; ensures 72-hour touchpoints are completed consistently and at scale. Directly reduces readmission risk and HRRP penalty exposure
03
MH/BH/SUD-Specific Care Coordination WorkflowsCloses the loop on behavioral health follow-up (FUH/FUM) and SUD initiation/engagement HEDIS measures. Provides structured referral tracking specifically designed for the fragmented BH network
04
Community Provider Connectivity (FQHC, CHW, CBO, social services)Enables omni-directional patient/client navigation incentivizing community organizations to engage better and support community health commitments
05
Referral Loop Closure w/Active StatusReal-time confirmation that a patient completed a referral — to specialist, PCP, or CBO. Eliminates the "we made the referral but don't know if they showed" blind spot that drives both leakage and HEDIS gaps
06
AI-Assisted Outreach & Work Queue PrioritizationReduces manual administrative burden on care coordinators and clinicians, addressing the physician burnout and administrative overload pain point directly without adding staff
Population HealthHICE AIVBCOpioid AbatementHIPAA / SOC2Multi-Site
~24%

Of adult ED visits are for non-urgent conditions, while broader analyses show over 50% may be avoidable with better access, care coordination, and community-based support.

~56%

Of emergency department utilization is driven by social, behavioral, and community-level factors with Medicare beneficiaries with unmet social needs facing 60% higher odds of ED use, reinforcing the impact of these non-clinical drivers.

Managed Care Value Drivers
01
Avoidable ED ReductionConnect high-risk Medicaid members to community resources, primary care, and social services before an ED visit occurs — using our COMPASS community engagement methodology proven to reduce avoidable Emergency Department visits and readmits that generate a significant per-case savings for the MCO.
02
HICE™ Powered Navigation CenterKnow whether plan members actually followed through. Closes knowledge gaps about local providers and services while analyzing user input to deliver human-centered resource recommendations optimized for plan members with complex health and social needs.
03
Case Worker EfficiencyEmbed a curated, GIS-informed community resource recommender directly into your case management workflow — as a standalone tool or widget within existing platforms. Eliminate the resource-hunting burden and redirect case worker time toward the member interactions that drive outcomes.
04
BH / SUD & Dual-Need CoordinationMedicaid members ages 18–64 are nine times more likely to have a mental health issue driving ED use. AccessMeCare™ connects BH/SUD-involved members to community behavioral health resources, peer support, and crisis diversion pathways — reducing preventable utilization at its most complex source.
05
Community Network InfrastructureThe COMPASS implementation process builds and trains a curated network of community-based organizations, FQHCs, and social service providers aligned with your plan's care goals — giving your team a scalable, accountable community engagement infrastructure that operates on your behalf.
06
Care Pathway OptimizationLost-to-Follow-Through Analysis pinpoints why and where patients fall through the cracks giving your team the evidence they need to improve — utilization trends, referral completion rates, community engagement activity, and financial performance.
HEDIS / StarsMedicaid MCO42 CFR Part 2Network AdequacyVBC Reporting
Stakeholder 04
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Payors & Managed Care Organizations

Medicaid Managed Care Organizations face financial exposure they cannot see and clinical outcomes they cannot control — because both are shaped by social, behavioral, and community-level factors that exist outside the medical perimeter. AccessMeCare™ gives your care management teams the infrastructure to reach members where traditional outreach fails, close the referral loop, and turn community engagement into measurable, reportable performance.

  • Reduce avoidable Emergency Department utilization by connecting high-risk members to appropriate community-based and primary care resources before a crisis occurs
  • Close the referral loop with in-system confirmation that members followed through on social service and community resource referrals — eliminating the open-loop problem that undermines care management programs ROI
  • Extend the reach of case managers by embedding a curated community resource recommender directly into existing workflows — reducing time spent hunting for resources and increasing time spent on member engagement
  • Activate and equip community health workers and CBOs with mobile tools that connect their field interactions back to your care management team in real time
  • Build the community trust infrastructure that traditional outreach cannot — using a CBPR-based engagement process proven to increase appropriate care-seeking by up to 180% over three years
  • Align community-based organizations, local health programs, and social service providers with your plan's self-interest — creating a coordinated network that works on your behalf beyond the clinical setting
  • Generate the outcome data your leadership and state Medicaid directors need — utilization trends, referral completion rates, and member engagement metrics that demonstrate measurable performance improvement
Stakeholder 05
🏛️

Government & Public Agencies

County health departments, community foundations, and public health agencies are accountable for community-wide outcomes — but are doing it with fragmented CBO networks, open referral loops, and no shared infrastructure to prove their programs are working. AccessMeCare™ gives government and public health leaders the best way to connect their entire service ecosystem, close the gap between programs and people, and produce the outcome data that justifies every dollar of grant funding invested.

  • Connect your entire network of CBOs, nonprofits, and service providers on a single co-branded platform — so every organization works from the same resource directory and every referral goes somewhere trackable
  • Close the referral loop with in-system confirmation that community members actually reached the services they were sent to — giving funders and elected officials the evidence they need
  • Equip community health workers and peer support specialists with mobile tools that connect their field interactions back to your coordinating organization in real time
  • Navigate community members to the right services based on where they are, what transportation is available, and what their actual social needs assessment shows — not just a static resource list
  • Build and sustain a community engagement network grounded in the proven COMPASS methodology — so adoption survives the first grant cycle and grows over time
  • Demonstrate measurable community health impact through configurable outcome dashboards built for grant reporting, board presentations, and elected official accountability
  • Give every nonprofit in your network access to the platform — including smaller CBOs that can't afford their own technology — through a freemium participation model that ensures no organization is left out
Program Areas Served
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Community Network Infrastructure
Deploy a co-branded, public-facing platform that connects your entire ecosystem of CBOs, health providers, and social service organizations — turning a fragmented collection of community relationships into a coordinated, accountable network with a shared resource directory and unified referral pathway.
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SUD/OUD Coordination
Connect crisis response, treatment access, and recovery support services in a single coordinated workflow — so individuals moving through the SUD and opioid recovery continuum don't fall through the gaps between organizations. Built for the community coordination requirements of opioid settlement fund deployments.
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Asset Mapping & Navigation
Give community members and care navigators a GIS-powered view of available services — with transportation overlay, dynamic routing, and a client-centered display that accounts for where someone actually is and how they can get there. Identify geographic access gaps and service redundancies that no static resource directory can reveal.
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COMPASS Implementation
AccessMeCare™ deploys with COMPASS — a community-based participatory research methodology proven to increase appropriate care-seeking by up to 180% over three years. COMPASS builds the community trust, organizational alignment, and shared ownership that ensures your platform is still in use long after the initial grant cycle ends.
$10.2M

The amount of supportive funding received by customers resulting from through their use of AccessMeCare™

15.5%

Of individuals used AccessMeCare™ to self-refer to mental/behavioral services.

SAMHSAJustice-InvolvedOpioid AbatementSDOHReentryBlock GrantsHIPAA Compliant
Platform Foundation

Shared infrastructure. Every stakeholder benefits.

Regardless of your role in the care ecosystem, every AccessMeCare™ deployment is built on the same secure, interoperable, AI-powered foundation.

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AccessMeCare Insights™

Real-time dashboards and outcome reporting that give every stakeholder the data they need to manage performance, prove value, and drive improvement.

ENGAGEMENT · OUTCOMES · REPORTING

HICE™ Navigation Engine

Proprietary recommendation engine that dynamically matches individuals to the most appropriate resources based on real-time need, eligibility, and availability.

AI · MATCHING · REAL-TIME
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COMPASS

Structured 90-day evidence-based implementation methodology with dedicated support from Heudia's informatics and deployment teams.

NETWORK · ENGAGEMENT · COMMUNITY
Get Started

Ready to see AccessMeCare™ in your environment?

Whether you're a clinic, hospital, health system, payor, or government agency — our solutions team will show you exactly how AccessMeCare™ addresses your specific challenges.

Questions? Call us: (866) 693-1158 · innovation@heudia.com