Pillar’s Chronic Care Monitoring System: Designed for Community Health, Built for Impact
Managing chronic conditions like diabetes, hypertension, COPD, and heart disease requires more than episodic check-ins. For nonprofit clinics, FQHCs, and community health programs, continuity of care must extend beyond the clinic walls. That’s where Pillar’s Chronic Care Monitoring Platform makes the difference.
Unlike one-size-fits-all solutions, Pillar by SocialRoots.ai is built for community care ecosystems—integrating chronic care management (CCM) with outreach coordination, remote monitoring, and social determinants of health (SDOH) workflows.
What is a Chronic Care Monitoring Platform?
A Chronic Care Monitoring Platform enables healthcare teams to continuously track, manage, and coordinate care for patients with long-term health conditions. It centralizes patient data, triggers alerts for clinical risks, supports care plan adjustments, and allows proactive outreach—ultimately reducing hospitalizations and improving population health outcomes.
Learn how chronic care models improve community outcomes
Why Community-Based Chronic Care Requires a Different Platform
Most chronic care tools are built for large hospital systems or commercial payers. But community clinics need :
- Support for underserved populations
- Offline and mobile access for outreach teams
- Grant-ready reports for compliance and funding
- Integration with SDOH and referrals
Pillar addresses these needs with a unified platform—designed for impact-driven care.
Key Features of Pillar’s Chronic Care Monitoring System
1. Unified Patient View
Access comprehensive client charts with real-time vitals, medication adherence, appointment history, lab results, and SDOH insights.
2. Care Plan Automation
Set up tailored care plans for chronic conditions like diabetes or hypertension. Automate tasks, reminders, and follow-up protocols across teams.
3. Remote Monitoring Integration
Seamlessly embed Remote Patient Monitoring (RPM) for vitals tracking—glucose, BP, weight—linked to alerts and care escalation.
4. SDOH + Case Management
Track social barriers to care with SDOH screening, referrals, and follow-ups integrated into care workflows.
5. Grant & Compliance Reporting
Generate reports on health outcomes, engagement metrics, and risk reduction—aligned to common grant KPIs and value-based care benchmarks.
Use Case: Chronic Care Monitoring for Rural Community Clinics
A coalition of CHCs in Texas implemented Pillar to support patients with diabetes and high blood pressure:
- Patients received RPM-enabled devices to monitor vitals remotely.
- Alerts were routed to case managers who provided coaching and medication support.
- SDOH screenings identified food insecurity, triggering nutrition referrals.
- Over 9 months, ER visits dropped by 38%, and program engagement rose by 52%.
Pillar enabled proactive care, not reactive treatment.
Pillar vs Other Chronic Care Platforms
| Platform | Focus | Pillar’s Advantage |
|---|---|---|
| Welkin Health | CRM-style workflows for chronic care | Lacks community care + SDOH integration |
| HealthSnap | RPM-focused | Doesn’t unify case management or grant workflows |
| eClinicalWorks CCM | Clinic-centric | Pillar supports field teams, shelters, and mobile clinics |
| WellSky | Population health platform | Pillar offers grassroots outreach + nonprofit reporting tools |
Why Pillar is the Best Platform Chronic Care Monitoring for Community Health
- Built for FQHCs, CHCs, and nonprofit clinics
- Includes both medical and social care workflows
- Supports multilingual outreach, offline sync, and mobile-first UX
- Tracks outcomes for funders, government programs, and value-based models
Related Use Cases and Features
Remote Patient Monitoring System
Why Pillar by SocialRoots.ai is the #1 Choice for Healthcare Reporting and SDOH Management
Frequently Asked Questions
Yes. It includes secure role-based access, audit logs, and HIPAA-compliant storage.
Absolutely. Pillar integrates RPM devices and links vitals to real-time alerts and care plans.
Yes. Pillar includes pre-built templates and data exports aligned to nonprofit funder KPIs.
Yes. Pillar supports mobile, offline-ready access for teams working in the community.
Conclusion
Managing chronic disease in community settings requires more than clinical dashboards. You need a platform that understands outreach, social needs, and resource gaps.
Pillar Community Healthcare Software by SocialRoots.ai offers a chronic care monitoring system tailored for mission-driven organizations. From patient tracking to SDOH referrals, it’s built to improve lives—and show the outcomes that matter.