Building Integrated, Continuity of Care Systems for High-Need Patients

Universal Enterprise Systems, LLC (UES) builds ambulatory, integrated care systems for population health management, with particular impact on high-need patients with multiple chronic diseases. Under both fee-for-service and bundled service care plans, UES works with local partners to capture a target population, expand healthcare and human service assets, and convert available care resources into a comprehensive, patient-centered care system that meets the complex needs of each community.

A sustainable business model with internal financing capacity supports UES’ scalable solution for seamless integrated care systems, built and sustained through community-wide collaborations across all providers through best-in-class:

Chronic Care Management
Services Integration and Care Coordination
Practice Management
Advanced Collaborative Technology & Data Analytics

UES is unique in working with physician groups, health plans, and hospitals transitioning into centers of ambulatory care networks, by filling the gap in integrated care services with internally financed resources for continuity of care—improving health outcomes and the bottom line for partner hospitals, providers and health plans.

These collaborative care systems transform communities as they achieve excellence in care to the benefit of all involved, particularly the communities’ most vulnerable and underserved members.

Who We Are

The UES core team of healthcare management, organizing, finance and clinical services leaders each has over 25 years’ experience (mostly working together) in the planning, development and implementation of integrated health and human services. They include top specialists in physician practice and management; collaborative case management and care coordination; hospital senior management, fiscal management and information systems; revenue cycle management; vendor services; and collaborative technology and network systems.

Collaboration with Industry and local provider partners completes our total solution for comprehensive, integrated care delivery systems:

Industry partners
UES brings together key actors in the healthcare enterprise, some of the most progressive applications and approaches in chronic disease management; diagnostic systems and equipment vendors; and leaders in smart computing and data analytics—into a scalable, vertically integrated solution for superior care delivery, health outcomes, cost savings and revenue enhancement.

Local partners
Hospitals, physicians groups, community service providers, nursing homes and others engage with one another in a coordinated, integrated delivery approach that enables optimal use of local resources and builds a value-based system for patient-centered care.

How We Work

The UES approach to population health management supports current national initiatives that aim to improve primary care through provider incentives under the ACO, Chronic Care Management, Patient Centered Medical Home, and other federal programs. Decades of experience in organizing integrated care networks in communities across the country inform how we go about enhancing community-based primary, specialty and acute care assets to improve patient care and wellness. Our process includes:
Assess the healthcare needs and resources of the local community, identifying levels of morbidity and gaps in care delivery for each sub-population consistent with national primary care norms and requirements;

Select a target population (focusing on patients with multiple chronic conditions) and build collaborative relationships with local primary care providers and acute care facilities that serve the target group;

Establish a care management/care coordination hub, either expanding ambulatory care operations of a local hospital or creating a new ambulatory care coordination center, fully staffed with a range of clinical, social support, and care management specialists;

Develop and implement a holistic care plan for each person being served through seamless collaboration with the individual’s primary care provider, that includes:
Comprehensive Panel of Diagnostic and Psycho-Social Assessments that are not readily accessed through the primary care provider, to better assess the level of patient clinical and social needs—for example, chronic care assessment, fall prevention, nuclear cardiac stress tests, neurological health tests, vascular screening and nerve conductor test, echocardiograms and M3 psychological tests as appropriate.

Full Spectrum Care Interventions—chronic disease management education, obesity management and diet control, cardiac and pulmonary rehab, smoking cessation counseling, kidney disease management, and family psycho-therapy sessions, in a range of individual, group, and peer support settings.

Continuous Biometric Home Monitoring for patients with complex needs that include monitoring for diabetes (glucose), hypertension (blood pressure), respiratory, weight and diet, as well as cardiac telemetry readings.

Assignment of a Personal Care Manager for Each Patient who coordinates care plan implementation, access to support services, continuous oversight, and monitoring of patient needs and challenges with adherence to care plans. Care manager also coordinates hospital discharge planning for continuity-of-care and follow-up services.

Home Coaching and Assistance by teams of trained community health workers for patients who need help and encouragement in adapting to and maintaining their care regimens.

Bi-weekly, monthly, and quarterly on-line multi-disciplinary review of patient care plans based on patients’ level of risk and need for intensive care coordination.

The UES collaborative care model supports seamless integration of providers and care functions… in the doctor’s office and in the home. This approach to value-based care puts UES in the forefront of national demonstration models that shift focus from episodic care to ongoing wellness support and prevention.

Timely, quality access to care that is so difficult for higher-needs patients to find, particularly in rural areas, is provided through extensive use of evidence-based practice, care protocols, and intensive care coordination.

Clinical and care coordination protocols are developed and used by the physicians and their collaborative provider team, ensuring compliance with highest quality care standards.

Key to the system is the full array of comprehensive, integrated services that adapt individual patient care profiles to personalized care plans.

Provider Benefits

Hospitals, physician practices and clinics, particularly in rural and underserved communities, face increasing pressure to do more with less. Whether cutting back services to reduce costs or struggling to meet loan obligations, many are looking for ways to grow their service capacity and their bottom line with limited budget and market opportunities.

The UES care system significantly expands existing capacity of participating providers and enhances hospital operations while improving care for high-need patients.

Benefits to the hospital include superior hospital discharge transition care, reduced re-admissions, heightened efficacy with existing provider relationships, and better management of DRGs.

Benefits to primary care providers include enhanced practice management, technology, and administrative efficiencies; care delivery capacity through added support for care coordination and documentation/reporting; and revenues through practice certification upgrade that qualify them for participation in national quality improvement programs and higher reimbursement rates.


The UES model integrates existing systems with advanced clinical technology and equipment, creating a collaborative intranet that supports:

real time monitoring and interventions across multiple platforms, providers and a vast target population, and

vertically integrated data systems that enable collaborative care management and population health management analysis.

Our collaborative workflow technology with predictive analytics brings services integration to a whole new level, extending the integrity of the clinical setting—from hospital, specialty, and primary care office—to remote care givers and into the home.

Vertical integration of data, accessed and shared from multiple sources, screened and augmented by intelligent computing, supports collaboration among providers and with patients at the point of care with optimal ease.

Sustainable Business Model

Critical mass of patients, providers and services—plus state-of-the art technology and data analytics— provide the foundation for enhanced care delivery, workflow efficiencies and cost savings in the UES care system. In addition, most services are billable fee-for-service or covered under bundled service plans sufficient to cover high-value services related to certain integrative care and health coaching supports that may not be reimbursable.

The UES business model aligns ‘smart’ computing with provider incentives, quality income streams, near term positive cash flow, and care improvement for high need patients, particularly critical in underserved markets.


Universal Enterprise Systems

Joe Eaglin
Senior Member

Mike Mayer
Senior Member