Close referral loops and care gaps across every site.
Community health centers run two coordination operations at once: the referral loop their providers order and the payer work their MCO rosters demand. Linear Health is operational AI that runs both currents in one accountable layer on top of your EHR, from outreach and scheduling to documented outcomes, with staff validating every exception before anything writes back.
- Exceptions carry a reason and a named owner
- Staff validation stands before write-back
- Outcomes return to the EHR and the quality team
Referral coordination and care gaps, connected.
Community health organization in the Chicago area, more than 100 providers across more than 20 locations, on athenahealth. Referral coordination, care gap closure and voice AI running across the network.
Where the coordination layer sits, and where it stops.
Three planes, one honest division of labor. The EHR stays the system of record; the coordination work happens around it; judgment stays with your people.
Your EHR, the system of record
Orders originate here and outcomes return here. Aunt Martha's runs Linear on athenahealth across multiple payer portals; athenahealth, eClinicalWorks, NextGen, and Greenway Health are established integrations, connected through standard health-data interfaces. There is no migration.
The coordination layer, both currents
Current A is the referral loop: orders matched with preference first, sent complete, tracked to the visit, and written back with the note. Current B is the payer current: MCO rosters ingested, validated against your records to filter gaps already addressed, then worked through outreach in English and Spanish to a documented outcome. Both converge in one exception ledger with named owners.
Your people, the decisions
All clinical decisions, roster ambiguities, and final validation before write-back or export stay with staff. Quality-measure calculation and UDS and HEDIS reporting remain your organization's: Linear documents the coordination activity behind them and does not generate or certify reports.
Common ownership, local visibility.
Multi-site coordination fails when every site invents its own workflow. Watch one exception cross the ownership line and come back.
The payer file lists a gap the chart shows as already addressed. The item pauses instead of triggering outreach.
The quality team sees the mismatch with full context, corrects the list logic once, and the fix applies everywhere.
Local staff keep visibility into their own patients throughout. Nobody loses sight of their panel to gain governance.
First workflow live in four weeks, on the systems you already run.
First workflow live in 4 weeks. From $2,000 a month. Flat monthly fee per workflow, sized to your volume. Security posture, access controls, and the BAA are documented on the security page.
Connect
EHR connection and payer-portal access are established. Owner: Linear, with your IT contact.
Map the workflows
Your referral states, roster sources, outreach rules, and escalation owners are configured. Owner: your operations lead, with Linear.
Validate on real work
Staff review live output side by side with the old process until the exception rules match how your center actually decides. Owner: your team.
Go live, keep the gate
Automation takes the routine; the staff-validation gate stays permanently. Owner: shared, by design.
Related FQHC reading.
Frequently asked questions
Direct answers for FQHC operational leaders.
What does FQHC referral management software actually cover?
For a community health center it covers two connected lanes of work: outbound referral coordination (matching, sending, patient outreach, scheduling, status tracking, and note return) and payer coordination (working MCO rosters and care-gap lists through outreach to a documented outcome). Linear Health runs both lanes in one operational layer on top of your EHR, with staff owning every exception.
How does Aunt Martha's use Linear Health?
Community health organization in the Chicago area, more than 100 providers across more than 20 locations, on athenahealth. Referral coordination, care gap closure and voice AI running across the network.
Can referral coordination and care-gap outreach share one workflow?
Yes, and that is the point of the design. A referral order and a care-gap roster item are different objects, so they run on separate rails, but they converge in one exception queue with shared ownership, shared outreach infrastructure, and one write-back path. Your team stops running two disconnected operations with two sets of spreadsheets.
How are MCO rosters and care-gap lists handled?
Payer gap files are ingested, matched against your records to filter patients whose gaps are already addressed, and the remainder enter outreach and scheduling workflows. Every attempt and outcome is documented, so your quality team works from an operational record rather than a stale spreadsheet. Staff validate the list logic and own anything ambiguous.
Does Linear Health generate our UDS or HEDIS reports?
No. Linear documents the coordination activity behind your quality work, completed referrals, outreach attempts, scheduled and completed visits, and gap-closure outcomes, and your organization owns quality-measure calculation, validation, and reporting. Linear is operational AI, not a reporting or clinical-quality engine.
What stays with our staff and clinicians?
Everything requiring judgment: clinical decisions of any kind, eligibility questions the payer data cannot resolve, patients unreachable after the configured outreach sequence, roster ambiguities, and final validation before anything is written back or exported. Exceptions surface with a named owner; nothing leaves the queue silently.
Does it work with athenahealth and our existing systems?
Yes. Aunt Martha's runs Linear on athenahealth across multiple payer portals. athenahealth, eClinicalWorks, NextGen, and Greenway Health are established integrations, connected through standard health-data interfaces. There is no EHR migration.
How long does implementation take, and what does it cost?
First workflow live in 4 weeks. From $2,000 a month. Flat monthly fee per workflow, sized to your volume. You pay nothing monthly until the workflow is live and processing real work. Every proposal shows your return against your own numbers. We build to 3x or better. Patient outreach runs in English and Spanish.
Bring a gap list and a week of referrals. Watch both currents run.
The working demo runs on your EHR and a real payer roster, not sample slides. First workflow live in 4 weeks. Every proposal shows your return against your own numbers. We build to 3x or better.