Infrastructure for
Longitudinal Care.

Traditional EHRs were built to document visits. OCHI was built to coordinate everything that happens between them.

Across chronic care management, remote monitoring, senior care, and community wellness — OCHI provides the operational infrastructure to support engagement, orchestration, and intelligent intervention at scale.


CCM
Chronic Care
Management
RPM
Remote Patient
Monitoring
DPP
Diabetes Prevention
Programs
BHI
Behavioral Health
Integration

Healthcare has moved
beyond the visit.

Most healthcare technology still operates as if care begins and ends with the encounter. OCHI was designed for the reality healthcare is moving toward: continuous, connected, longitudinal care.

Traditional Systems
Built around visits
Document encounters
Workflow follows providers
Episodic interventions
Siloed operational systems
Static documentation
OCHI
Built around continuous programs
Coordinate longitudinal care
Workflow follows rules and cohorts
Continuous engagement
Connected orchestration
Dynamic operational workflows

A configurable
longitudinal care engine.

OCHI is built on four operational primitives that compose every program on the platform. Programs change by editing configuration — not by writing code.

Cohorts
Events
Rules
Actions
01
Cohorts
Patient populations grouped by condition, age, program enrollment, risk profile, location, or any other criterion. Cohort membership determines what events apply.
02
Events
Scheduled, recurring, or triggered interactions — vitals captures, assessments, content delivery, coaching sessions, wellness check-ins, and care team check-ins.
03
Rules
Operational logic that evaluates incoming data and decides what should happen — out-of-range readings, missing data, schedule deviations, and escalation thresholds.
04
Actions
What happens when a rule fires — notify a care team member, message the patient or family, schedule a follow-up, escalate to a clinician, log an audit event.

One platform.
Multiple longitudinal care models.

OCHI supports the full spectrum of care management programs — from community wellness to Medicare-reimbursable clinical services.

Chronic Care Management (CCM)
Coordinate ongoing care for patients with multiple chronic conditions. Improve engagement, compliance, and continuity while supporting Medicare reimbursement workflows.
Remote Patient Monitoring (RPM)
Monitor biometrics remotely with integrated workflows, automated alerts, engagement tools, and care team communication built for scale.
Remote Therapeutic Monitoring (RTM)
Support therapy adherence, musculoskeletal programs, respiratory monitoring, and digital therapeutic workflows with full audit trails.
Behavioral Health Integration (BHI)
Integrate behavioral health coordination into primary and chronic care programs through collaborative care models and structured documentation workflows.
Diabetes Prevention & Wellness (DPP)
Deliver evidence-based wellness and prevention programs — including DPP and Blood Pressure Self-Management — through community organizations and virtual coaching teams.
Senior Care & Aging in Place
Continuous wellness engagement, escalation workflows, family coordination, and intelligent longitudinal support for aging populations.
Patient Engagement & Call Centers
Support virtual care teams and clinical call centers with workflows designed for high-touch longitudinal engagement at enterprise scale.
Social Determinants of Health (SDOH)
Coordinate community resources, referrals, and support services that address whole-person care needs alongside clinical programs.

Solving the gaps
EHRs leave behind.

Medicare-supported care programs like CCM, RPM, RTM, and BHI have demonstrated strong clinical outcomes and cost savings — yet many providers struggle to implement them effectively.

Common Barriers

  • Administrative burden
  • Staffing shortages
  • Low operational efficiency
  • Limited patient engagement
  • Inadequate EHR functionality
  • Compliance complexity
  • Lack of scalable workflows

Core Capabilities

Patient engagement automation
Care plan management
Secure patient communication
SMS and digital assessments
Virtual care coordination
Clinical documentation
Audit-ready reporting
EHR interoperability
Multi-disciplinary workflows
Population health management
Telemedicine support
Device integration (RPM/RTM)

Built on a foundation
you can defend.

OCHI runs PHI-rich workflows, reimbursable Medicare programs, and longitudinal care across multiple organizations. Compliance is foundational — not a feature.

HIPAA Security Rule Alignment
Full Security Rule policy posture with HITRUST Common Security Framework policies in place.
Business Associate Agreements
BAAs available. Breach policy, disaster recovery, and business continuity programs documented and reviewed.
Audit Logging
Complete audit trails across events, workflows, rule evaluations, and access with role-based control at the data-element level.
Medicare-Aligned Workflows
Designed to support reimbursable Medicare workflows including CCM, RPM, RTM, and BHI with workforce security and training programs.

Powering the future of
senior longitudinal care.

OCHI serves as the foundational platform behind Vitae Care — combining longitudinal care infrastructure with next-generation AI-driven engagement designed for aging populations.

Together, OCHI and Vitae represent a new operational model for aging-centered care: continuous engagement, intelligent orchestration, and coordinated support extending far beyond episodic interactions.

As healthcare shifts toward aging-in-place and continuous care models, infrastructure capable of supporting longitudinal engagement becomes foundational — not optional.

Learn about Vitae Care
Vitae Care

Continuous engagement for aging populations.

AI-driven engagement designed for older adults, built on OCHI's longitudinal care infrastructure. Escalation workflows, family coordination, and intelligent daily support — all within one connected platform.

Schedule a Conversation

Designed for today's
healthcare organizations.

From health systems to community YMCAs, OCHI supports the full spectrum of organizations delivering longitudinal care at scale.

Health Systems
Independent Practices
MSOs
ACOs
Community-Based Organizations
YMCAs & Wellness Organizations
Behavioral Health Organizations
Long-Term Care Programs
Population Health Initiatives
Care Management Call Centers
Value-Based Care Programs

A platform built for the shift
from episodic to programmatic care.

Origin

Originally commissioned through an initiative involving the North Carolina Medical Society Foundation and developed by Greenlight Ventures, OCHI began as the operational infrastructure for community-based wellness programs.

The first deployments — Diabetes Prevention, Blood Pressure Self-Management, and similar evidence-based interventions — required something traditional EHRs were never designed for: managing groups, running coaching workflows, capturing outcomes session by session, and integrating virtual and in-person delivery. So we built the platform around different primitives: not visits and codes — cohorts, events, schedules, rules, and outcomes.

Expansion

The same engine that ran a community DPP program turned out to be the right engine for everything else that lives between visits. Direct EHR-to-EHR messaging made OCHI deployable inside provider organizations. Cohort-targeted engagement enabled scalable longitudinal interventions. Vitals cadence and out-of-range flagging supported Medicare-reimbursable chronic care management.

The newest configuration extends the engine to senior care and aging-in-place — combining operational orchestration with AI-driven engagement designed for older adults.

Greenlight Ventures

OCHI operates as part of the Greenlight Ventures family of healthcare operating companies, alongside related capabilities serving care delivery and clinical operations. The platform's continued development, governance, and operational track record reflect a parent that has built and run healthcare infrastructure for years.

Programs at Origin
  • Diabetes Prevention Programs (DPP)
  • Blood Pressure Self-Management (BPSM)
  • Weight Loss & Lifestyle Coaching
  • Behavioral Health Support
  • Chronic Disease Education
  • Community Wellness Programs
The OCHI Difference
  • Purpose-built for longitudinal care — not another EHR module
  • Community + clinical integration in one workflow platform
  • Virtual, hybrid, and in-person care delivery
  • Operationally scalable for enterprise call centers and multi-site orgs
  • Compliance and reimbursement-ready for CCM, RPM, RTM, BHI

Care beyond the visit —
questions we hear most.

What does "care beyond the visit" actually mean?
It refers to the work of coordinating patient health between scheduled clinical encounters — daily monitoring, recurring engagement, longitudinal interventions, and intelligent escalation. An increasing share of clinical work happens outside the appointment, not inside it.
Why can't a traditional EHR support longitudinal care?
EHRs were architected around documenting episodic encounters. They don't natively support defining cohorts, scheduling recurring events, applying rules to incoming data, and triggering automated actions between visits. Longitudinal care platforms are built around those primitives from the start.
How do organizations operate Medicare care management programs at scale?
CCM, RPM, RTM, and BHI are reimbursed for activities that happen continuously between provider visits. To operate them at scale, organizations need infrastructure that automates recurring outreach, ingests device data, evaluates rules, escalates when needed, and captures audit-ready documentation for reimbursement.
How do you scale longitudinal engagement without scaling staffing in lockstep?
Move the recurring work into the platform: automated outreach, cohort-driven scheduling, rule-based triage, and exception-based clinical review. Care teams intervene where their judgment matters; the platform handles everything else.
What is longitudinal data capture in healthcare?
The structured collection of patient information across time — daily check-ins, device readings, assessment results, patient-reported outcomes, and care team interactions. It's the data foundation required for chronic care management, remote monitoring, behavioral health, and senior care programs.
How is longitudinal data made audit-ready?
Every data point and every action triggered by it — notifications, escalations, schedule changes — must be logged with a timestamp, an originating source, and a role-based access trail. This is foundational for reimbursement, clinical defensibility, and regulatory compliance.

Why organizations
choose OCHI.

01
Purpose-Built for Longitudinal Care
Not another EHR module. Designed from the ground up for ongoing care management, patient engagement, and wellness programs.
02
Community + Clinical Integration
Connect providers, care teams, and community organizations within one coordinated workflow platform.
03
Virtual & Hybrid Care Delivery
Manage programs delivered in-person, remotely, or through hybrid care models — all within a single configurable system.
04
Operationally Scalable
Support enterprise call centers, multi-site organizations, and distributed care teams without scaling operational fragmentation alongside it.
05
Compliance & Reimbursement Ready
Built to support Medicare reimbursable workflows including CCM, RPM, RTM, and BHI — with the audit infrastructure to defend it.

Build the future
between visits.

Healthcare continues long after the appointment ends. OCHI provides the infrastructure to coordinate that care intelligently, continuously, and at scale.

Response Time
We respond within one business day
Platform Inquiries
Demos, diligence, and partnerships
Vitae Care
Senior care and aging-in-place programs