How the BloomCare Partnership Works
One Coordinated Care Infrastructure
Our model is designed to make care management easier for provider practices while creating a more connected experience for patients. BloomCare works alongside your team to understand your population, align workflows, identify eligible patients, deliver whole-person support, and provide structured reporting so your practice can scale care without building the full infrastructure alone.
BloomCare is not a disconnected vendor. We function as a natural extension of the practice’s care infrastructure. Our workflow connects provider direction, RN-led care coordination, patient engagement, monitoring, escalation, BloomAccess™, and analytics into one organized care model.
1 Practice Alignment
BloomCare begins by meeting with the provider group to understand the practice’s patient population, clinical priorities, workflows, payer mix, staffing model, technology environment, referral patterns, escalation preferences, and care management goals.
- Patient population and chronic disease burden
- Current workflows and staffing capacity
- Payer mix and Medicare population
- Provider priorities and program goals
- Escalation pathways and technology tools
2 Patient Identification
BloomCare helps identify patients who may benefit from BloomCore™, Integrated Care Programs, BloomAccess™, and future specialty pathways. This includes reviewing eligibility opportunities across CCM, RPM, TCM, BHI, and PCM.
- CCM, RPM, and BHI Integration
- TCM / BloomTransitions™
- PCM (Principal Care Management)
- Integrated Care Programs & BloomAccess™
3 Outreach & Enrollment
BloomCare contacts eligible patients and authorized caregivers to explain the program, answer questions, confirm interest, review available services, and support enrollment. The process is designed to feel supportive and clear.
- Explain BloomCare services in simple language
- Confirm patient interest and structured consent
- Identify caregiver involvement when appropriate
- Introduce available programs and support options
4 RN Assessment
Each enrolled patient receives a thorough RN-led onboarding assessment designed to capture clinical, functional, behavioral, medication, lifestyle, caregiver, and social factors that influence health outcomes.
- Diagnoses and chronic condition history
- Medication list and adherence barriers
- Functional status, mobility, and lifestyle factors
- SDOH and behavioral screening needs
5 Individualized Care Plan
BloomCare creates and maintains an individualized care plan based on the patient’s diagnoses, risk level, preferences, goals, care gaps, provider direction, and identified support needs. It evolves gracefully over time.
- Diagnosis-specific benchmarks & medication adherence
- Symptom threshold monitoring priorities
- Nutrition, movement, and lifestyle pathways
- Escalation triggers & special BloomAccess™ channels
6 Support & Monitoring
Patients receive recurring RN-led engagement, education, care plan reinforcement, medication support, monitoring review, symptom check-ins, and follow-up based on their assigned programs.
- Monthly RN outreach and proactive tracking loops
- RPM trend evaluation & device monitoring data
- Nutrition, lifestyle, and mobility coaching
- Behavioral health monitoring & caregiver check-ins
7 Escalation & Coordination
When BloomCare identifies concerning symptoms, abnormal readings, missed engagement, or post-discharge risks, the care team follows structured escalation workflows to loop back safely to the primary practice.
- Immediate notification to provider practice channels
- Urgent routing to defined point-of-contact targets
- Same-day urgent telehealth through BloomAccess™
- Documented escalation histories saved directly to charts
8 Performance Intelligence & Optimization
BloomCare provides visibility into enrollment, engagement, monitoring activity, care gaps, escalations, patient needs, program performance, and operational opportunities to optimize your continuous infrastructure layer.
- Active panel volumes & cross-program enrollment rates
- Physiological trend deviations & clinical alerts
- BloomAccess™ utilization and care gap indicators
- Documentation validation & compliance tracking data
One Coordinated Care Infrastructure
BloomCare connects the pieces practices often struggle to manage separately: patient outreach, RN assessments, care planning, remote monitoring, behavioral health screening, Integrated Care Programs, BloomAccess™, escalation workflows, and performance reporting.
Ready to build a more connected care management model?
BloomCare partners with healthcare practices to identify eligible patients, implement the right programs, and deliver RN-led longitudinal care with scalable workflows and clear reporting.
Schedule a Partnership Discovery CallCOMPLIANCE DISCLAIMER: BloomCare supports provider-directed care through care coordination, patient engagement, monitoring, documentation support, reporting, and escalation workflows. Program availability, patient eligibility, reimbursement, scope of services, referrals, BloomAccess™ availability, labs, imaging, and clinical workflows may vary by payer requirements, medical necessity, provider documentation, contractual arrangements, geography, partner availability, and applicable federal and state regulations. BloomCare does not replace emergency services, provider medical decision-making, or licensed clinical judgment.
How We Partner
IMPLEMENTATION & GO-LIVE
From Partnership Alignment to Patient Enrollment
BloomCare uses a structured implementation process designed to align the partnership, establish clear workflows, review patient populations, and prepare the RN-led care infrastructure before patient outreach begins.
BloomCare is designed to align with the practice’s care model while providing the RN-led workflows, technology, access pathways, and operational infrastructure needed to support patients between visits.
A CLEAR PARTNERSHIP MODEL
Your Practice Leads the Care. BloomCare Extends the Infrastructure.
A successful longitudinal care model requires clear clinical and operational responsibilities. The provider practice remains at the center of medical decision-making and the provider-patient relationship. BloomCare provides the RN-led infrastructure and structured workflows needed to support patients between visits.
YOUR PRACTICE
- Maintains provider oversight and the provider-patient relationship
- Directs medical treatment and clinical decision-making
- Establishes clinical priorities and treatment plans
- Serves as the patient’s primary or specialty clinical practice
- Reviews applicable clinical information and communications
- Bills applicable services according to the agreed contractual and billing workflow
BLOOMCARE
- Delivers RN-led longitudinal patient support
- Conducts structured patient outreach and engagement
- Performs RN assessments and supports individualized care planning
- Monitors symptoms, trends, engagement, and identified care gaps
- Supports medication adherence, patient education, and care coordination
- Identifies acute or time-sensitive patient concerns
- Coordinates applicable BloomAccess™ pathways for timely provider evaluation and next-step care coordination
- Supports time capture, documentation, and billing-readiness workflows
- Provides structured analytics and performance visibility
The provider practice remains at the center of medical decision-making. BloomCare functions as an extension of the practice’s care infrastructure—helping support patients throughout the time between provider visits.
CONTINUOUS PARTNERSHIP
The Partnership Does Not End at Launch
BloomCare continuously evaluates patient engagement, monitoring trends, care gaps, BloomAccess™ activity, program participation, and operational performance. The goal is to help practices maintain a care infrastructure that evolves alongside their patient population and clinical priorities.
Population Review
Review enrollment opportunities, changing patient needs, clinical risk patterns, and emerging care gaps across the patient population.
Clinical & Operational Optimization
Evaluate RN workflows, patient engagement, monitoring activity, care coordination processes, and opportunities to strengthen longitudinal care delivery.
Performance Visibility
Provide structured visibility into enrollment, engagement, monitoring activity, care gaps, BloomAccess™ activity, and program performance.
Program Expansion
Evaluate opportunities to expand patient populations, BloomCore™ programs, Integrated Care Programs, and future specialty care pathways as organizational needs evolve.
BloomCare is built as an ongoing infrastructure partnership designed to support continuous care delivery, visibility, and responsible scale.
BloomCare partners with healthcare organizations to identify potentially appropriate patient populations, align clinical and operational workflows, and implement RN-led longitudinal care infrastructure designed to support patients between visits.