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 Reporting & 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.
Request a BloomCare Strategy 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.