Patient Case Management & Care Navigation

Coordinate care across a caseload — cases, care programs, providers, and referrals with a patient portal.

Move every patient forward — navigators work their caseload and never lose a referral, supervisors watch program health across the board, referral partners submit and track referrals through their own portal, and patients follow their own case without chasing phone calls.

Built for care-navigation teams coordinating patients across programs, providers, and outside partners — where the case that slips through is the patient who suffers.

Your navigators can

Work their own caseload — every case, next step, and program in one view
Take a referral from intake to enrolled without a spreadsheet in between
Connect patients with the right providers from a shared directory

Your supervisors can

See program health and caseload across every navigator at a glance
Rebalance caseloads before anyone drowns

Your referral partners can

Submit referrals through their own portal and track the status themselves — no more "did you get my fax?"

Your patients can

Referral routing, reminders, and audit logging run automatically underneath. Row-level security scopes Admin, Supervisor, Navigator, Provider, Patient, and Referral Partner to exactly their own slice.

What's included

7 user roles: Admin, Supervisor, Navigator, Provider, Patient, Referral Partner, Partner Intake (public)
12 data tables: Patients, Cases, Tasks, Referrals, Care Programs, Providers, Referral Partners, Consents
18 workflows: Referral routing with consent gates, task reminders, SLA escalation, consent expiry
16 email templates: Case, task, referral, consent and escalation notices
8 AI agents: Intake Triage, Stalled Case Monitor, Case Summary & Handoff, Patient Message Drafter, plus role assistants
Sample data: Demo users for every role + seeded patients, cases and referrals — optional at install
Security: Row-level security scopes every role to its own slice

Data tables (12)

Organizations — The care organization the whole app is scoped to — its name, contact email and settings, which every case, note, document and audit entry rolls up to for row-level security.
Patients — The people you are helping — demographics, contact details, language and the portal login that lets each patient follow their own care.
Care Programs — The care programs you enroll patients into, with the checklist of tasks each new case should start with.
Providers — Your directory of clinicians and community providers who receive referrals and report back on outcomes through their own portal.
Referral Partners — Outside agencies that send you referrals or receive them from you, with their own portal to submit and track without phone calls.
Cases — The heart of the app: every open case with its program, priority, assigned navigator, supervisor and target close date, so nobody slips through.
Tasks — The follow-ups that keep a case moving — welcome calls, check-ins and paperwork, each with an owner and a due date that drives reminders.
Referrals — Referrals in and out of your organization, tracked from submission to outcome with consent verified before anything is shared.
Notes — The running narrative on each case — call summaries, visit notes and escalation flags written by navigators, tied to the patient and case so the next person has the whole story.
Documents — Files attached to a case — intake forms, records and letters uploaded by navigators or by patients from the portal, and shared back with the patient only once consent is on file.
Consents — Each patient's signed consents and expiry dates — the gate that decides whether documents can be shared and referrals can go out.
Audit Log — Append-only record of who changed what and when — case edits, logins and exports — kept for compliance review, readable by Admins and never edited by hand.

User roles (7)

Admin — Runs the organization: users, providers, partners and programs, plus a read-only window into the audit log.
Supervisor — Assigns and rebalances caseloads, watches program health across every navigator and handles escalations before they become crises.
Navigator — Owns a caseload day to day — intake, tasks, notes, referrals, documents and consents for their own patients only.
Provider — A portal for clinicians to review the referrals sent to them and record a decision, without seeing anything beyond what they need.
Patient — A portal where patients see where their case stands, who is helping, and the documents shared with them, and can upload their own.
Referral Partner — A portal for outside agencies to submit referrals and follow the status of the ones they sent or received.
Partner Intake (public) — A secure, login-free intake link partners can use to submit a referral and get a reference number back.

Workflows (18)

W1 Case intake — Numbers every new case, opens it, and either hands it to the assigned navigator or alerts the supervisor that someone still needs to pick it up.
W2 Assignment / reassignment (RLS re-key) — When a case changes hands, moves the open tasks, notes, documents and referrals to the new navigator and lets them know it is theirs.
W3 Task denormalization — Stamps each new task with its case's organization and navigator so it lands in the right caseload, and assigns it to that navigator by default.
W4 Note denormalization — Files each new note under the right organization and case navigator and stamps who wrote it and when, so notes stay visible only to the people on that case.
W5 Document intake — Files each uploaded document against the right case and patient, and tells the navigator when a patient has uploaded something from the portal.
W6 Document share consent gate — Blocks sharing a document with a patient until they have an active consent on file, then notifies the patient when it is safe to share.
W7 Referral creation + consent gate — Sends a new referral to the receiving provider and partners only after consent is verified; otherwise holds it and asks the navigator to act.
W8 Referral outcome — When a provider completes or declines a referral, records the outcome and tells the navigator and the sending partner.
W9 Consent lifecycle (gate maintenance) — Keeps the consent gate honest: revoking a consent withdraws every shared document, and activating one releases referrals that were on hold.
W10 Task reminder — Emails each navigator the day before a follow-up is due so nothing is forgotten.
W11 Task overdue — Flags tasks that have slipped past their due date and nudges the owner, feeding the supervisor's overdue counts.
W12 SLA escalation ladder — Escalates cases past their target close date to the supervisor, and to the org admin if they stay stuck for more than three days.
W13 Case closure — Closes out a case cleanly: records the close date, cancels leftover tasks and notifies the supervisor of the outcome.
W14 Consent expiry ladder — Warns the organization 30 days before consents expire and automatically expires the ones that lapse.
W15 Partner intake — Turns a partner's referral into a patient stub and a new case, then routes it to the triage queue so a navigator can pick it up.
W16 Audit - case record events — Writes an audit entry every time a case is created or changed, so supervisors and admins can trace the full history of any case for compliance review.
W17 Audit - logins — Records every user login in the audit log so admins can see who accessed the app and when; ships switched off until you are ready to turn it on.
W18 Audit - exports — Logs a record whenever case data is exported, giving admins a trail of what left the system, by whom and when, for compliance review.

Email templates (16)

E1 Case assigned
E2 Task due soon
E3 Task overdue
E4 New referral received
E5 Referral outcome updated
E6 Referral status update (partner)
E7 Document shared with you
E8 Patient uploaded a document
E9 Consent required - action held
E10 Consent revoked
E11 Case escalated (SLA breach)
E12 Skip-level escalation
E13 Case closed
E14 Consents expiring soon
E15 New partner referral to triage
E16 Unassigned case at intake

AI agents (8)

A1 Intake Triage — Suggests the right program and priority for each new intake and flags possible duplicate patients before a case is opened.
A2 Stalled Case Monitor — Ranks the cases most at risk of stalling and proposes the next step for each.
A3 Case Summary & Handoff — Drafts a case chronology for handoffs, audits or closure so the next person has the whole story.
A4 Patient Message Drafter — Writes patient-facing messages in English or Spanish with no protected health information included.
Navigator Assistant — A navigator's daily companion for questions about their own caseload, tasks and referrals.
Program Assistant — Answers supervisors' questions about program health, caseload balance and open escalations.
Care Companion — Explains a patient's care plan and case status in plain language inside the patient portal.
Partner Referral Assistant — Lets referral partners ask where their sent referrals stand without calling the office.

Categories: Case Management, Healthcare