Method and System for Automated Healthcare Care Coordination and Care Transitions

A method of care coordination comprising:

• selecting, by a care coordination system, a patient for care coordination based in part on a patient diagnosis and data analytics;
• assigning, by the care coordination system, a predetermined patient care flow plan to the patient based in part on the patient diagnosis;
• modifying, by the care coordination system, the predetermined patient care flow plan in response to input from at least one of a healthcare provider and the patient, and generating a customized patient care flow plan for the patient;
• executing, by the care coordination system, the customized patient care flow plan;
• and
• engaging the patient by providing to the patient at least one of patient scheduling, notifications, a personal health record, patient home monitoring, and patient education and medication information materials.

A non-transitory, tangible computer-readable storage medium having computer-executable instructions stored thereon that, if executed by a care coordination system, cause the care coordination system to perform operations comprising:

• selecting, by the care coordination system, a patient for care coordination based in part on a patient diagnosis and data analytics;
• assigning, by the care coordination system, a predetermined patient care flow plan to the patient based in part on the patient diagnosis;
• modifying, by the care coordination system, the predetermined patient care flow plan in response to input from at least one of a healthcare provider and the patient, and generating a customized patient care flow plan for the patient;
• executing, by the care coordination system, the customized patient care flow plan;
• engaging the patient by providing to the patient at least one of patient scheduling, notifications, a personal health record, patient home monitoring, and patient education and medication information materials.