For Community Care Hubs

The data backbone that turns your social care agency into a healthcare partner.

Interoperable by default. Built so the CBOs in your hub deliver as one team and report as one entity.

app.monami.io / community-care-hubs
M MonAmi
  • Home
  • My Clients
  • All Clients
  • Information & Referral
  • Care Management
  • Nutrition
  • OAAPS Reporting
  • SmartLists
SU
State Unit
on Aging · FY26
JR
Clients Eleanor "Ellie" Hayes
EH
CLIENT

Eleanor "Ellie" Hayes

ACTIVE
02/14/1943 · age 83 · Asheville, NC
ami-4f82e1c 1 program suspension
Dashboard Profile Notes Activity More
Compliance Alerts ADL Limitations missing & 2 more 3
Pinned Notes Apr 18, 2026
Daughter called — Ellie is hospitalized for an acute event. Pause services through the end of the month.
Key Profile Info
Date of birth 1943-02-14
Gender Female
Poverty line At or below poverty
Living status Alone, at home
01
Interoperable, by default
FHIR R4, HL7, open REST API, secure SFTP — Mon Ami speaks the languages your healthcare partners actually use, so a referral from an MCO, hospital, or ACO lands in the right CBO's queue without a middleware project.
02
One hub, every member CBO
Multiple member CBOs deliver locally; your hub aggregates, reports, and invoices the healthcare partner as one entity — so payers see a single accountable network instead of negotiating with dozens of small organizations.
03
SDOH outcomes your partners trust
Standardized SDOH screening, intervention tracking, and outcome reporting — in the formats your payers actually ask for, not approximations of what your hub thinks they want.
Why switch

We hear the same two complaints from every team we talk to.

Both have the same root cause: your software was built before anyone in your job description was expected to work this way. Mon Ami exists because that's no longer okay.

Reason 01
Your software fights you.
Reason 02
Your data is trapped.
01
Reason #1

Built for the way Community Care Hubs actually work.

Multi-payer contracting, distributed CBO delivery, closed-loop referrals back to healthcare — captured in one record, reported in every format your partners need.

A pile of spreadsheets per payer
CARES Client Manager — [CLIENT: WHITFIELD, MARCIA ID# 0047188214] _ ×
FileEditViewRecordeportsToolsWindowHelp
Demographics Eligibility Services Assessments Care Plan Notes Provider Billing
WHITFIELD
MARCIA
L
XXX-XX-4421
04/12/1941
F
02 - WHT/NH
W - Widowed
214 PINEHURST CIR APT 4B
PINEHURST
NC
28374
37125
04
SOUTH CENTRAL
02
(910) 555-0117
(910) 555-0282
NC0918274421
1EG4-TE5-MK72
Service Enrollments
SVC
PROVIDER
UNIT TYP
START
END
FUND CODE
STATUS
318
COASTAL AAA
MEAL
02/04/24
TII-C1
ACT
412
COASTAL AAA
HOUR
01/18/24
TII-B
ACT
218
TRIANGLE TX
TRIP
03/02/24
04/30/24
STA-FN
CLS
506
FAMILY CARE
HOUR
CGV-C
WLT
USER: jmiller SVR: cares-prd-04 SESS: 02:14:38 RECORD 1 OF 14,028 NUM CAPS
One record, every payer
M MonAmi
  • Home
  • My Clients
  • All Clients
  • Information & Referral
  • Care Management
  • Nutrition
  • OAAPS Reporting
  • SmartLists
SU
State Unit
on Aging · FY26
JR
Clients Eleanor "Ellie" Hayes
EH
CLIENT

Eleanor "Ellie" Hayes

ACTIVE
02/14/1943 · age 83 · Asheville, NC
ami-4f82e1c 1 program suspension
Dashboard Profile Notes Activity More
Compliance Alerts ADL Limitations missing & 2 more 3
Pinned Notes Apr 18, 2026
Daughter called — Ellie is hospitalized for an acute event. Pause services through the end of the month.
Key Profile Info
Date of birth 1943-02-14
Gender Female
Poverty line At or below poverty
Living status Alone, at home
02
Reason #2

Unlock the data that proves the value of social care.

Hospitals, MCOs, and ACOs all ask the same question: did your services reduce cost and improve outcomes? Mon Ami unifies SDOH screening, intervention activity, and member-level outcomes — so when contracts come up for renewal, the answer to 'was it worth it?' is one report, not a quarterly project.

MonAmi
ANALYTICS
Dashboards
Member outcomes
SDOH delivery
Closed-loop referrals
Payer reports
Network activity
SmartLists
Food-insecure members
Housing follow-up due
Open referrals
Dashboards / Member outcomes · YTD

SDOH outcomes & member outreach

Period: YTD All payers All CBOs
Members screened
1,240
▲ 287% YoY
Interventions delivered
88%
▲ 26 pts YoY
Closed-loop rate
91%
▲ 37 pts YoY
SDOH interventions · 12 months
All payers · across 14 member CBOs
Food Housing Transportation Utilities
Referrals closed-loop
YTD · across all healthcare partners
Closed-loop · 86
In progress · 9
Unreached · 5
Insight. Members screened positive for food insecurity who completed an HDM intervention had 22% fewer ED visits in the following 90 days — across both Medicaid MCO and ACO partner panels. Open cohort
SDOH outcomes
Screen → intervention → outcome, end-to-end
Member outreach
Closed-loop referrals across every payer
Network roll-up
Every member CBO, every payer, one view
An industry-leading data and analytics platform — not a CRM with a reports tab.
And yes — every regulation your team answers to is already in the system.
HIPAASOC 2 Type II42 CFR Part 2WCAG 2.1FHIR HL7
How Community Care Hubs use Mon Ami

One platform. The modules that matter for your work.

Mon Ami is modular. Community Care Hubs typically deploy the highlighted modules below, with the rest available as your needs grow.

Case Management Core

Manage clients across every CBO in your hub — assessments, care plans, scheduled services, follow-up — in a single shared record so a person referred from a hospital sees the same care team coordinating their full plan.

SDOH Screening & Follow-up Core

PRAPARE, AHC HRSN, and most state- or payer-specific SDOH screeners — with results flowing directly into intervention planning, follow-up reminders, and outcome reporting.

Outcome Reporting to Partners Core

Outcome packets generated per payer — closed-loop reports, SDOH outcome dashboards, ROI summaries, and value-based contract attestations in the formats healthcare partners actually require.

Billing

Invoice each healthcare partner against the right contract — MCO, ACO, hospital, FQHC, state grant — with per-rate-sheet validation, denial tracking, and aging in the same record as the delivered services.

Healthcare Partner Integration Core

Bidirectional integration with healthcare partner referral platforms and EHRs — every referral and outcome flowing in the right direction, in the right format.

Service Reporting Core

Live cohorts across payers, member CBOs, and SDOH domains. Build it once, share it across the network — no SQL, no overnight batch, no IT ticket.

FAQ

The questions directors actually ask us.

If you're evaluating Mon Ami for an RFP or a board, these come up every time. Don't see yours? Get in touch — we'll answer in plain language.

How long does implementation typically take?

Because Mon Ami is a configurable COTS product — not a custom build — you skip the multi-year timelines and risk of bespoke development. Our implementation timelines have agencies up and running in a fraction of the time it takes with our competitors. Weeks, not years.

Can we migrate from our existing system?

Yes. We’ve executed large-scale migrations for state agencies with decades of historical data — including from SAMS, WellSky/Harmony, custom Access databases, home-grown Salesforce builds, and spreadsheets — without data loss. Our migration team handles data mapping, validation, and cutover. And we don’t bill by the hour for it.

Is Mon Ami truly ADA accessible?

Yes — this isn’t a checkbox claim. Mon Ami is built to WCAG 2.1 AA standards and tested with screen readers including JAWS and NVDA. We have blind case managers actively using the product for their daily work, which is the proof point most accessibility claims can’t back up.

How does Mon Ami handle interoperability with our other systems?

We know that your agencies operate within a network, and we routinely integrate with external systems. We have experience integrating with state government systems, HIEs, EHRs, other database solutions, and everything in between. Our architecture makes that straightforward: open REST API, HL7 FHIR R4, secure SFTP, and structured data formats. Interoperability is a design standard here, not a project.

What does your support model look like?

Our support team isn’t just technically sharp — they know your world. They understand aging and disability services, OAAPS and NORS, and compliance requirements, so they can advise on configuration, workflow, and data strategy, not just answer tickets. Response times are excellent, but that’s the floor, not the ceiling. Ask us for client references — they’ll tell you better than we can what the experience is like.

What is Mon Ami's pricing?

Pricing is always scoped to the agency’s unique needs. What we can tell you is what’s always included — no surprise charges. Most enterprise software vendors grow revenue through change orders, seat fees, and storage limits. We don’t. Every license includes, at no additional cost: unlimited user seats, unlimited client and case records, unlimited file storage, adding or amending data fields, forms, and assessments, data export and ad hoc reporting, and all improvement and version updates. Why? Because we believe our incentives should align with yours. Charging per seat quietly discourages agencies from adding new staff — which leads to shared logins and real security risks. Charging for field changes or new reports penalizes agencies for adapting to shifting funding and regulatory requirements. We’ve seen what that model does, and we built ours as a deliberate alternative.

Let's talk

Run your Community Care Hub end-to-end — one record, every payer.

30-minute scoping call. No slideware. Just a conversation with someone who's done this before.