Modernize Care Coordination Without Replacing Your EHR

How a U.S.-Based Community Health System Improved Care Coordination with Pillar

A U.S.-based community health system partnered with Pillar by SocialRoots.ai to modernize care coordination while continuing to use its existing Electronic Health Record (EHR) systems. Rather than replacing established clinical platforms, the organization implemented Pillar as an interoperable care management platform that connected clinical, social, and operational workflows.

Using FHIR and HL7 interoperability standards, Pillar unified fragmented care coordination processes, streamlined Social Determinants of Health (SDOH) management, and provided care teams with a centralized view of every patient's journey. The result was a more connected care delivery model that improved collaboration, increased operational visibility, and reduced the administrative burden on clinical teams.

Key Highlights

Following the implementation of Pillar, the organization was able to:

• Modernize care coordination without replacing Epic or Oracle Health (Cerner)
• Centralize patient care management across multiple programs
• Integrate SDOH screening into everyday clinical workflows
• Replace spreadsheet-based tracking with unified client records
• Improve care team collaboration and leadership visibility
• Automate reporting for quality improvement and value-based care initiatives
• Build a scalable foundation for future healthcare innovation

Customer Background

The organization is a U.S.-based community health system serving diverse urban and semi-rural populations through primary care, behavioral health, chronic disease management, and community health programs. Its care model extends beyond traditional clinical services by addressing Social Determinants of Health (SDOH), including housing stability, transportation access, food insecurity, and other non-medical factors that influence long-term health outcomes.

While the organization's existing EHR systems effectively supported clinical documentation and patient records, care coordination activities were managed across multiple disconnected applications, spreadsheets, and manual processes. As patient needs became more complex and value-based care initiatives expanded, these fragmented workflows created operational inefficiencies and limited visibility across care teams.

Leadership recognized the need for a centralized care management platform that could complement, not replace, their existing EHR investments.

The Challenge

Although clinical care remained strong, several operational challenges affected care coordination across programs.

Care coordinators spent valuable time switching between systems to access patient information. Care plans were tracked in spreadsheets, which made collaboration difficult and increased the risk of inconsistent documentation.

SDOH information was often collected during patient interactions but was not consistently documented in structured formats. As a result, identifying social risk trends, measuring intervention outcomes, and producing reports required significant manual effort.

The organization also faced challenges in:

• Coordinating care across multiple departments and programs
• Maintaining consistent documentation across teams
• Tracking patient progress over time
• Generating accurate operational and compliance reports
• Providing leadership with real-time visibility into care outcomes

Replacing the existing EHR environment was not a practical option due to cost, implementation risk, and potential disruption to clinical operations. Instead, the organization needed a solution that would integrate seamlessly with its existing technology landscape while strengthening care management capabilities.

Why Pillar

After evaluating multiple care management solutions, the organization selected Pillar by SocialRoots.ai because it functions as a comprehensive care coordination platform rather than simply a referral management tool.

Pillar enables healthcare organizations to extend the capabilities of existing EHR systems by providing configurable care management workflows, centralized patient records, SDOH management, analytics, and interoperability within a single platform.

Key capabilities that influenced the decision included:

• FHIR and HL7-based integration with existing EHR systems
• Configurable care plans and encounter documentation
• Built-in SDOH screening and tracking
• Centralized client records across programs
• Real-time analytics and reporting dashboards
• Enterprise-grade security and HIPAA-compliant architecture

This approach allowed the organization to preserve its existing clinical workflows while modernizing care coordination across the enterprise.

Implementation Approach

The implementation followed a phased rollout designed to minimize disruption while encouraging user adoption.

The project began by integrating Pillar with the organization's existing EHR systems using interoperability standards. Patient information was synchronized to create a unified foundation for care management.

Next, care coordination workflows were configured to support each department's operational needs. Standardized care plans, encounter documentation, and SDOH assessments were developed to create consistency across programs.

Training sessions were conducted for care coordinators, nurses, behavioral health teams, social workers, and program managers. The phased deployment enabled staff to adopt new workflows gradually while maintaining continuity of patient care.

Within a short period, teams successfully transitioned from disconnected processes to a centralized care coordination environment.

Pillar in Action

Unified Client Records

Pillar consolidated clinical information, care plans, encounters, and documented social needs into a comprehensive longitudinal client record. Care teams no longer relied on multiple spreadsheets or disconnected systems to understand a patient's history.

Integrated SDOH Management

Custom SDOH assessments were embedded directly into intake and follow-up workflows, allowing care teams to identify social risks earlier and connect patients with appropriate community resources and support services.

Collaborative Care Planning

Care plans became living documents that could be updated collaboratively across departments. Providers, care coordinators, and support teams worked from a shared view of patient goals, interventions, and progress.

Standardized Documentation

Encounter documentation was standardized using configurable forms and workflows, improving consistency, supporting compliance requirements, and reducing duplicate data entry.

Analytics and Operational Visibility

Leadership gained access to real-time dashboards displaying care coordination activities, program performance, patient engagement trends, and operational metrics. This reduced manual reporting efforts while enabling faster, data-driven decision-making.

Business Impact

Implementing Pillar transformed the organization's care coordination capabilities without disrupting existing clinical systems.

The organization achieved:

• Improved collaboration between clinical and community care teams
• Better visibility into patient journeys across multiple programs
• Consistent documentation and standardized workflows
• Reduced dependence on spreadsheets and manual tracking
• Faster reporting for leadership and quality improvement initiatives
• Enhanced monitoring of SDOH-related interventions
• Stronger operational readiness for value-based care programs

By centralizing care management within a single platform, care teams spent less time navigating disconnected systems and more time supporting patients throughout their care journeys.

Lessons Learned

The organization discovered that improving care coordination does not require replacing existing EHR systems. Instead, extending those systems with an interoperable care management platform created greater flexibility while preserving existing technology investments.

The project also reinforced several important principles:

• Whole-person care requires visibility into both clinical and social factors.
• Standardized workflows improve collaboration across multidisciplinary teams.
• Real-time analytics support faster operational and clinical decision-making.
• Interoperability enables healthcare organizations to modernize without disrupting established clinical environments.

These lessons continue to guide the organization's approach to delivering connected, patient-centered care.

Modernize Care Coordination with Pillar

Healthcare organizations looking to improve care coordination, strengthen SDOH management, and support value-based care do not have to replace their existing EHR systems.

Pillar by SocialRoots.ai works alongside Epic, Oracle Health (Cerner), and other leading EHR platforms to centralize care management, streamline workflows, improve interoperability, and deliver real-time operational insights.

Whether your organization is expanding community health programs, improving population health initiatives, or modernizing care coordination, Pillar provides a scalable foundation for delivering connected, whole-person care.

Ready to modernize care coordination without replacing your EHR? Explore how Pillar can help your organization build more connected, efficient, and patient-centered care workflows.