Capabilities
Care Plans That Get Paid — and Get Results
Navigator360° generates AI-powered, TEFCA-connected care plans from your patients’ existing data — so your care team can focus on delivering billable, person-centered social care navigation for Medicare patients living with chronic conditions.
Get Paid to Address Social Needs. We Handle the Paperwork.
Medicare now reimburses for assessing and addressing Health-Related Social Needs (HRSN) through Community Health Integration (CHI) and Principal Illness Navigation (PIN) billing codes — but capturing that revenue requires documentation infrastructure most organizations don’t have: care plans.
Navigator360° is built for exactly this. Our care plan technology generates the clinical and social documentation your billing team needs, aligned to CHI and PIN requirements, from data you already have. For healthcare organizations, that means new Medicare revenue without new administrative burden. For social care organizations and CBOs, it means your navigation work finally gets recognized — and reimbursed.
OCL connects the clinical record to the social care record so that every hour your team spends navigating patients to services is a billable, documented, auditable hour.
Don’t Start From Scratch. We Already Have the Data.
TEFCA-Connected Care Plans, Generated in Seconds
Your patients already have a health history. Their clinical data lives in EMRs, HIEs, Homeless Management Information Systems, and social care platforms. The problem isn’t a lack of data — it’s that no one has unified it into an actionable care plan your team can actually use.
Navigator360° connects to existing data sources through TEFCA and other interoperability frameworks to generate a comprehensive, AI-powered Unified Care Plan from records that already exist. Minimal manual data entry. No starting from a blank template. A complete, structured plan — ready for your care team and your patient to review and approve.
Generate
Pull clinical and SDOH data from Health Information Exchanges, Homeless Management Information Systems, and existing assessments to auto-generate a complete care plan in minutes.
Organize
AI automatically maps data across disparate sources into standardized semantic categories — chronic conditions, Housing, Food, active interventions, goals — so nothing gets missed and everything is easy to find.
Personalize
Receive AI-generated recommendations for services, activities, and interventions tailored to the patient's specific conditions, social needs, and stated goals — right inside the care plan.
Approve Together
Care team members and patients review, refine, and approve the plan collaboratively. The patient sees their goals in plain language. The clinician sees the clinical picture. Everyone is working from the same document.
Care Plans Centered on Patients Needs & Goals
AI that Gets Your Team the Data You Need
Generating a care plan from existing data is only valuable if the AI respects what matters most: the patient’s voice, the care team’s clinical judgment, and your organization’s workflows.
Our AI and governance layer is designed to do exactly that. It surfaces the data most relevant to each care team member’s role — a social worker sees SDOH gaps and referral status; a nurse sees chronic condition management priorities; a care coordinator sees open tasks and upcoming appointments. And at every step, the patient’s goals, preferences, and consent are at the center of what gets generated.
Patient-Centered by Design
Care plan content reflects the patient's own goals and preferences alongside clinical best practices. Patients aren't handed a document — they help shape it.
Role-Based Relevance
Our governance layer enforces HIPAA's "minimum necessary" standard while ensuring each care team member sees the information most relevant to their role. No information overload. No blind spots.
Robust Consent Enforcement
Robust consent enforcement governs every data exchange across clinical and social care providers, with a full audit trail for compliance and billing documentation.
Care Plan Templates: Operationalize Best Practices at Scale
A Unified Care Plan captures the whole person. A Care Plan Template operationalizes your organization’s best practices for a specific population — so your care team isn’t reinventing the wheel for every patient with similar needs. OCL offers templates built around pre-defined clinical and social cohorts, incorporating evidence-based interventions aligned with Medicare quality measures and payer requirements.
Multiple Chronic Conditions (MCC)
25% of patients with multiple chronic conditions account for 65% of healthcare costs. Our MCC eCare Plan template structures interventions around the conditions most likely to drive readmissions and social care utilization — giving care teams a head start on high-risk patient management.
SDOH & Social Needs Navigation
Templates built around specific HRSN categories — housing instability, food insecurity, transportation — align navigation activities with CHI and PIN billing documentation requirements.
22+ Social Care Domains
Adaptable to the operational workflows and data needs of over 22 social care domains, from housing to behavioral health to preventive care delivery.
Custom Templates
OCL works with clients to build additional templates around mutually agreed-upon cohorts and best practices. If your organization has a protocol that works, we help you scale it.
The Results You Can Measure
Expanded Revenue
Capture Medicare reimbursement for CHI and PIN navigation services with documentation automatically generated to meet billing requirements. Social care organizations can bill for health-related data collection and navigation activities in their communities.
Time Saved
Auto-generate care plans from existing patient data — saving care teams hours of manual documentation per patient and reducing duplication across clinical and social care handoffs.
Better Outcomes
Align SDOH interventions, clinical care, and patient goals in a single shared plan. Close care gaps. Track referral outcomes. Continuously improve based on what works.
Real Collaboration
Give every member of the care team — physicians, nurses, social workers, community health workers, and the patient themselves — a shared, up-to-date view of the plan. No more siloed notes. No more missed handoffs.
Care Plans are available through Navigator360°, Care360°, and SHIE360° — so your organization can access unified, billable, AI-generated care coordination wherever your team works.
Start generating billable care plans today
Navigator360° connects your existing data to CHI and PIN billing — with AI-powered care plans your team and your patients can actually use.