How the U.S.-Based Community Health System Modernized Care Coordination With Pillar

A U.S.-based community health system partnered with Pillar by SocialRoots.ai to modernize care coordination without replacing its existing EHR systems. By integrating Pillar using FHIR and HL7 standards, the organization unified fragmented workflows, improved visibility into Social Determinants of Health (SDOH), and strengthened care delivery across programs—while reducing administrative burden and improving operational outcomes.

Key Takeaways

With Pillar in place, the organization was able to:

• Centralize care coordination without replacing Epic or Cerner
• Capture and act on SDOH data directly within clinical workflows
• Replace spreadsheet-based tracking with unified client charts
• Improve care team efficiency and leadership visibility
• Support value-based care initiatives and compliance reporting

Background

The organization is a U.S. community health system serving urban and semi-rural populations across multiple regions. Its services include primary care, behavioral health, chronic disease management, and SDOH-focused programs addressing housing, transportation, and food access.

While existing EHR systems effectively supported clinical documentation, care coordination and population health workflows operated outside the EHR—spread across third-party tools and spreadsheets.

As patient complexity increased and value-based care requirements expanded, leadership recognized that fragmented workflows were limiting both care quality and operational scalability.

Addressing Whole-Person Care

Leadership understood that non-medical factors were significantly influencing outcomes. Transportation barriers, housing instability, and food insecurity frequently surfaced during patient interactions—but this information was rarely captured in structured, reportable formats.

Without consistent SDOH data:

• Care teams struggled to intervene early
• Leadership lacked visibility into program effectiveness
• Reporting for grants, quality programs, and value-based contracts was manual and time-intensive

The organization needed a solution that could connect clinical care, social needs, and outcomes—without disrupting existing workflows or forcing an EHR replacement.

The Challenge

Despite delivering strong clinical care, the organization faced persistent operational challenges:

• Care coordination data lived outside the EHR
• SDOH information was inconsistent and difficult to track at scale
• Spreadsheets were used to manage care plans and follow-ups
• Reporting required manual effort across multiple systems
• Leadership had limited real-time visibility into outcomes

Most importantly, replacing existing EHR systems was not an option due to cost, risk, and operational disruption.

Why Pillar

The organization was not looking to replace its EHR. Instead, it needed a platform that could sit alongside existing systems—connect data across programs, standardize workflows, and provide a single source of truth for care coordination.

After evaluating several options, the organization selected Pillar by SocialRoots.ai for its ability to function as an interoperable care management layer, not just a referral or point solution.

Key decision factors included Pillar’s ability to:

• Integrate seamlessly with existing EHRs using FHIR and HL7
• Support care management and SDOH workflows—not just referrals
• Provide configurable forms, care plans, and encounter documentation
• Deliver real-time analytics without manual reporting
• Maintain enterprise-grade security and HIPAA compliance

Solution

Pillar was implemented as a centralized care management platform layered on top of existing systems.

The rollout followed a phased approach to ensure continuity of care:

• Initial EHR integration and data normalization
• Care plan and encounter workflow configuration
• SDOH screening and tracking setup
• Staff training with gradual, role-based adoption

This approach allowed teams to modernize workflows without disrupting daily operations and achieved high adoption within weeks.

Pillar in Action

Comprehensive Client Charts

Clinical history, social needs, encounters, and care plans were unified into a single longitudinal view—eliminating spreadsheet-based tracking.

SDOH Identification & Intervention

Custom forms embedded SDOH screening into intake and follow-up workflows, enabling teams to identify risks and connect them directly to targeted interventions.

Personalized Care Plans

Care teams documented goals, interventions, and outcomes in shared, living care plans accessible across programs and departments.

Encounter Notes & Documentation

Standardized encounter tracking improved documentation consistency, compliance, and reporting accuracy.

Analytics & Dashboards

Leadership gained real-time visibility into program performance, care gaps, and population health trends.

Impact

“Pillar gave us visibility we never had before—without forcing our teams to change how they deliver care.”

Since implementing Pillar, the organization has:

• Improved care coordination across clinical and social programs
• Significantly reduced reliance on spreadsheets and manual reporting
• Increased visibility into SDOH-driven risks and outcomes
• Strengthened compliance and audit readiness
• Enabled faster, data-driven decision-making at the leadership level

Care teams now spend less time managing disconnected systems—and more time supporting patients across their care journeys.

Lessons Learned

Whole-person care requires more than clinical documentation alone. To improve outcomes at scale, healthcare organizations must:

• Make social risk factors visible and actionable
• Support care teams with workflows—not workarounds
• Use real-time data to guide interventions, not just retrospective reporting

By modernizing care management without disrupting existing EHRs, the organization positioned itself for sustainable, value-based care delivery.

Ready to Modernize Care Coordination Without Replacing Your EHR?

Pillar by SocialRoots.ai helps healthcare organizations centralize care coordination, operationalize SDOH, and gain real-time insight—while working seamlessly alongside existing EHR systems.