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StreetEMR - Unified Care Continuum Portal

The Unified Care Continuum Portal (UCCP) is a web based system that is being developed to provide a single point of access to a client's plan, which would span services rendered to the client from multiple organizations. This will enable providers and coordinators to view the entire continuum of care being provided to a client, rather than just their own care plans. It will enable better coordination between systems, and reduce any overlap in services that might currently exist due to a lack in coordination. It will also establish a more streamlined and coordinated case management process with the client.

The UCCP will be built on top of PCIC's web-based Electronic Medical Record (EMR) system, integrating into existing care coordination and care plan functionality that is already present in the system.

Unified Care Continuum Portal

Secure role based access

The UCCP is a secure web application allowing user access via a Multi Factor Authentication (MFA) system and a Secure Socket Layer (SSL). Access to the system is role based, with the PCIC client coordination team lead identifying organizations and users who should have access to the clients care plan. Once access control policies have been established for a client, users from participating organizations can add and edit data in their part of the care plan, but have view only access to other organizations care plan for the client.

Care Plan Development Platform

The care plan development platform is the central piece of the UCCP, where organizations can create and define care plans for clients, along with defining the steps involved in achieving the goals of the care plan. The platform will be designed to follow the Goal Negotiated Care (GNC) model, whereby goals are defined together with the client, taking the client's input into account and their ability to achieve it. The system will assist in scheduling out the steps involved and assigning responsibility to the members of the care teams as well as the client. Notification services (discussed under the communication platform below) will help both the staff and the client stay on track with their tasks and goals.

Another key functionality of the care plan development platform is the ability to view care plans that have been defined for the client, by other participating organizations. Having viewing access to this information will help organizations coordinate services across the system as a whole, preventing duplication and having a comprehensive picture of the care being provided to the client across systems.

Communications Platform

The communication platform provides a collaborative environment for care coordinators and providers to easily communicate with each other directly through the UCCP. In addition to this, the communication platform will also assist in keeping both the staff and client on track through the use of automated notifications via emails, phone calls and text messages. This will also help prevent tasks from falling through the cracks.

Referral Platform

The referral platform in the UCCP will enable organizations to easily refer a client to another participating organization to receive services from the organization that may be required by the client. This feature will drive off of the care plan for the client. Integration with the communication platform will allow for automated communications in the referral platform as well as a smooth handoff.

Dashboards & Reporting

The UCCP will be dashboard driven, where outcomes and client tracking data point will be accessible via Interactive dashboards and visualizations. The UCCP dashboards will be structured similar to the overlap analysis dashboards, providing visuals at the client, provider, organization and overall system level. Drill down features will enable for reviewing data from an aggregated high level to a detailed client level.

In addition to dashboards, reporting features will be provided based on the needs of the participating organizations.


In addition to tracking client care plans, the UCCP will also track time, effort and resources of staff from the participating organizations, proving a transparent platform for accountability across systems.

In addition to providing accountability, these measures will assist in better identifying and predicting resources needs for a particular client, given their level of complexity.

StreetEMR UCCP UCCP Unified Care Continuum Portal care plans unified care plans population health

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At PCIC we envision a coordinated health safety-net where all stakeholders share data to make better decisions.

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To improve healthcare quality and costs for the vulnerable in our community through data integration and care coordination.

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