AI-powered workflows that identify and engage the right patients at the right time to prevent avoidable readmissions and improve outcomes.
Rising utilization, fragmented data, and workforce shortages make it hard for care teams to spot risk early and intervene before avoidable events occur. Care managers are overwhelmed by low-value alerts, inconsistent data, and manual follow-up that limit their ability to focus on the patients who need them most.
Limited staff capacity delays outreach, misses transition windows, and reduces monitoring for chronically ill and rising-risk patients.
Without predictive insights, care teams rely on scheduled check-ins instead of early detection of deterioration or readmission risk.
Avoidable readmissions and penalties strain financial performance and reduce shared savings.
Key insights live in separate systems, making it difficult to form a complete picture of patient risk.
Lightbeam’s integrated TCM, CCM, and Rising-Risk Management solutions combine real-time data, AI-enabled risk prediction, and automated patient engagement to help organizations intervene earlier, reduce avoidable admissions, and manage patient needs across the continuum of care—at scale.
- Predict & prioritize at-risk patients using real-time clinical, behavioral, & SDOH factors.
- AI-enabled workflows support medication adherence, scheduling, & monitoring.
- Aggregate data for a comprehensive view of clinical, social, and utilization risks.
- Generate savings from avoidable admissions, unnecessary utilization, & readmission penalties
- Accelerate time to intervention with real-time alerts and configurable patient rules.
- Improve cross-team care coordination and reduce manual follow-up workload.
Provider Compass is Lightbeam’s embedded, AI-powered solution that delivers real-time HCC coding guidance directly within the provider’s EMR workflow. Without requiring a separate login or external portal, Provider Compass automatically surfaces critical information, such as quality measure gaps, risk scores, and HCC coding opportunities, at the point of care. Daily updates ensure the latest insights are always available, helping providers take timely, informed action that improves both care and reimbursement accuracy.
- Eliminates Frustration of Toggling between portals
- Automates EMR Alerts for Patients with Quality Measure Gaps or Risk Adjustment Recapture/Suspect Coding Opportunities
- Expands within the EMR to display patient-specific details
- Consolidates and Displays Patient Treatment history in Summary Tab
- Strengthens Risk Adjustment Precision
- Provides Real-Time Visibility Into Patient Records
Automate delivery of key reports and data visualizations to providers and care teams on any schedule. These include patient follow-up lists and performance metrics tied to financial incentive programs, seamlessly aligning with workflows that drive quality performance.
- View Recapture Rates at Each Level of Organization and
value-based contract - Identify Patients With High Value Recapture Opportunities Dynamically Who are Rescheduled
- Receive Automatic Reports For Patients With HCC Coding Opportunities Based On Appointment Scheduled
- Retrospective and Concurrent Chart Reviews
Reduce Cost and Improve Outcomes
Kootenai Care Network (KCN), a clinically integrated network supporting over 200 providers across Idaho and Washington, implemented Lightbeam’s Chronic Care Management program to enhance care continuity and reduce utilization.
They saw a 26% decrease in hospital admissions and a 15% decrease in ED visits per thousand patients for engaged CCM patients, generating $50,000 per month in revenue for CCM billing across three contracts, with $740,000 in cost savings.
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