Turn complex patient needs into coordinated action.
RE-Assist helps primary care teams identify patient needs, coordinate care plans and referrals, and document eligible Advanced Primary Care Management services, while keeping clinicians and coordinators in control.
Get a tailored 30-minute walkthrough based on your patient population and current workflow.
THE CHALLENGE
Primary care does not stop when the visit ends.
Every day, patient needs arrive through records, messages, calls, forms, referrals, and family requests. When that work is spread across systems and staff, important next steps can be delayed, duplicated, or lost.
Too much information to assemble
Care teams spend valuable time reviewing charts, locating details, and piecing together clinical and social needs.
Too many disconnected next steps
Referrals, forms, care plans, outreach, and community resources often live in different workflows with unclear ownership.
Important work is difficult to sustain
Between-visit coordination takes time and expertise. Practices need a repeatable way to deliver, document, and support that work.
RE-Assist brings the information, people, and next steps together in one human-guided workflow.
THE PLATFORM
One connected workflow for complex care.
RE-Assist helps care teams move from scattered patient information to clear, coordinated action—without taking clinical judgment away from the people responsible for care.
See what needs attention
Bring relevant clinical information, social needs, care-team input, and patient circumstances into a more complete view.
Know what happens next
Surface care gaps and possible next steps for review, then assign work to the appropriate team member.
Coordinate through completion
Manage care plans, tasks, referrals, communication, and follow-up with clearer ownership and status.
Document the work
Organize care-management activity into reviewable, billing-aligned documentation.
Measure progress
Track enrollment, workflow activity, referral completion, unresolved barriers, and financial performance.
From patient information to coordinated follow-through.
1.
Connect
RE-Assist is designed to connect with the systems your team already uses, bringing relevant patient information into a shared workflow.
2.
Understand
Human-guided technology helps review the chart, summarize clinical and social context, and surface possible needs, risks, and care gaps.
3.
Coordinate
Care teams can create and assign tasks, build care plans, connect patients with providers and community resources, and track referrals.
4.
Document
RE-Assist helps organize care-management activity and documentation around the workflow and applicable service requirements.
5.
Measure
Operational reporting helps teams see what was completed, what remains unresolved, and where the program can improve.
Recommendations remain subject to care-team review. RE-Assist supports clinical and operational judgment; it does not replace it.
Make advanced primary care more practical.
What is APCM?
Advanced Primary Care Management creates a monthly reimbursement pathway for qualifying Medicare patients, but practices still need the people, processes, documentation, and technology to deliver the required services.
RE-Assist helps turn those requirements into a repeatable workflow.
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Identify patients who may qualify for APCM review.
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Support outreach, consent, and enrollment workflows.
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Create and maintain patient-centered electronic care plans.
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Coordinate referrals, transitions, communication, and follow-up.
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Organize activity into billing-aligned documentation.
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Track program participation, work completed, and financial performance.
Eligibility, documentation requirements, coverage, cost sharing, and payment can vary. RE-Assist supports practice workflows and review; it does not guarantee reimbursement.
CAPABILITIES
The tools care teams need to keep work moving.
AI-assisted chart pre-screening
Surface relevant patient information, potential gaps, and possible next steps for care-team review—without asking staff to begin every case from a blank page.
Whole-patient summaries
Bring clinical information and social factors into a concise, usable view that helps teams understand what may affect the care plan.
Electronic care plans
Create and maintain plans that clarify goals, interventions, responsibilities, referrals, and follow-up for the care team, patient, and caregiver.
Referral and resource coordination
Match patient needs with clinical and community services, manage outreach, and follow referrals through completion or documented resolution.
Workflow and task management
Assign ownership, due dates, status, and escalation so work is visible even when multiple people or organizations are involved.
Patient and caregiver access
Give patients and authorized caregivers clearer access to plans, referrals, appointments, resources, and next steps.
Reporting and insights
Monitor participation, workflow volume, completion, barriers, and financial performance to improve the program over time.
BENEFITS
Better for the care team. Clearer for the patient. More sustainable for the practice.
For Care Teams
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Spend less time searching, sorting, and manually tracking work.
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See patient needs and responsibilities more clearly.
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Keep clinicians and coordinators in control of decisions.
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Track referrals and follow-up through resolution.
For Practices
Create a repeatable complex-care and APCM workflow.
Support eligible revenue with billing-aligned documentation.
Gain visibility into work completed and unresolved.
Expand care-management capacity without relying on one person’s memory.
For Patients and Caregivers
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Understand the care plan and what happens next.
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Stay connected to referrals, appointments, and resources.
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Receive help that considers both clinical and social needs.
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Reduce the burden of navigating disconnected services alone.
WHO WE SERVE
Built for teams carrying complex care forward.
Independent Primary Care
Create a practical care-management workflow without building a large new department.
Community Health Centers
Connect clinical needs, social barriers, care plans, referrals, and follow-up across multidisciplinary teams.
Rural and Community-Based Care
Extend coordination capacity where staffing, specialty access, transportation, and service availability create additional barriers.
Health Systems and Care Networks
Standardize complex-care workflows and create clearer coordination across sites, service lines, and community partners.
NAVIGATION SERVICES
Technology when it helps. Human support when it matters.
Some practices need more than a platform. RE-Assist Navigation can add support for patient outreach, resource connection, referral follow-up, and care-plan coordination based on the organization’s needs.
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Patient outreach and engagement
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Clinical and community-resource navigation
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Referral follow-up and barrier resolution
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Support for patients and family caregivers
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Coordination with the practice care team
Why RE-Assist Is Different
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Clinical and social context together: Understand the factors that may shape whether a care plan can succeed.
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From need through follow-through: Move from chart review to tasks, plans, referrals, documentation, and measurement.
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APCM-ready workflow: Support the operational elements practices need to build a sustainable service.
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Human-guided technology: Keep clinicians and coordinators responsible for review and decisions.
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Patient and caregiver connection: Make plans and next steps more accessible to the people living with them.
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Designed to complement the EHR: Add coordination capabilities without positioning RE-Assist as a replacement for the patient record.
INTEGRATION AND TRUST
Designed to fit healthcare workflows.
RE-Assist is building standards-based connectivity that can bring information into the coordination workflow and return approved summaries, care plans, or reference documentation to connected systems.
Interoperability
SMART on FHIR connectivity for supported EHR environments.
Secure access
Single sign-on using OAuth2/OIDC and role-based access controls.
Human review
Care teams review surfaced information, recommendations, and documentation before action.
Traceable workflow
Assigned tasks, status, and activity history create clearer accountability.
FOUNDER AND MISSION
Built from the realities of care coordination.
RE-Assist founder Ashley Barrow spent years helping medically vulnerable patients move among hospitals, post-acute settings, community services, and home. She saw how often patients, families, and care teams were asked to make high-stakes decisions using incomplete information and disconnected processes.
During the COVID-19 period, Ashley and her son Aaron began building a better way to connect patients and care teams with the information, services, and next steps they need. That original idea has grown into RE-Assist: a human-guided platform designed to make complex care easier to coordinate and harder to lose.
What We Measure With Early Partners
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Patients identified, contacted, consented, enrolled, and retained
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Care plans created and maintained
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Tasks and referrals initiated, completed, overdue, or unresolved
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Time from identified need to first action and resolution
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APCM claims submitted, paid, denied, or adjusted
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Net program revenue after technology, service, billing, and staffing costs
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Staff adoption, workload, and satisfaction
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Patient understanding, engagement, and experience
RE-Assist is working with early clinical partners to measure how connected workflows affect staff capacity, referral follow-through, patient engagement, and care-management revenue.
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Ready to unify care coordination and see measurable ROI?
Request a Demo → Get a tailored 30-minute walkthrough for your service lines.