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Population Health Coordinator Mobile App Achieves 19% Readmission Reduction

About the Client

The client is a large health system building a population health management program to improve care coordination and reduce hospital readmissions. Care coordinators were conducting home visits and outreach calls but lacked access to real-time patient data and tools in the field. To address these challenges, the health system partnered with Zymr to build a mobile-first solution integrated with their existing Epic EHR.

Key Outcomes

19% Reduction in 30-Day Readmissions Within 12 Months
Enabled Mobile Data Access for 5 Active Care Management Programs

Business Challenges

Care coordinators did not have access to actionable patient data during home visits and outreach activities. Critical information such as risk scores, care gaps, and care plans was only available within the EHR, limiting effectiveness in the field.

The lack of mobility and offline access created inefficiencies, especially in areas with limited or no connectivity. Coordinators had to rely on manual notes and later re-enter data into the system, increasing the risk of errors and delays.

Care coordination workflows were fragmented, with no standardized tools for outreach communication, documentation, or tracking interventions. This impacted patient engagement and continuity of care.

The health system needed a mobile solution that could deliver real-time insights, support offline functionality, and seamlessly integrate with their Epic EHR to enable efficient, data-driven care coordination.

Business Impacts / Key Results Achieved

Zymr developed a mobile application that empowered care coordinators with real-time and offline access to critical patient data, improving care delivery and operational efficiency.

  • 19% Reduction in 30-Day Readmissions Within 12 Months
  • Adopted Across 5 Active Care Management Programs
  • Improved Care Coordination Efficiency in Field Operations
  • Reduced Manual Data Entry and Documentation Delays

Strategy and Solutions

Zymr designed and implemented a mobile-first population health application tailored for care coordinators working in the field.

  • Offline-Capable Mobile Application
    Developed an iOS application that functions fully offline, enabling uninterrupted access during home visits in low-connectivity areas.
  • FHIR-Based Epic Integration
    Integrated the app with Epic EHR using FHIR R4 standards to provide real-time access to patient data and ensure seamless synchronization.
  • Risk Stratification and Care Gap Insights
    Delivered patient risk scores and care gap lists to help coordinators prioritize interventions effectively.
  • Care Coordination Workflows
    Enabled structured workflows for outreach calls, care plan documentation, and intervention tracking.
  • Automated Data Sync
    Ensured all data captured offline is automatically synced back to Epic, reducing manual entry and improving data accuracy.
  • Scalable Population Health Platform
    Established the app as a central data entry point supporting multiple care management programs across the health system.
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