Multi-agency Care Coordination Hub

Connecting organisations. Coordinating care. Creating wellbeing.

Whether you're delivering social prescribing, WorkWell or Integrated Neighbourhood Teams, RIVIAM brings Primary Care, community services, Local Authorities and VCFSE partners together so they can coordinate care in one secure, digital care hub.

Make joined-up working a reality

Delivering neighbourhood healthcare requires a new model of care, where health, social care and VCFSE partners work seamlessly together around the needs of each person. But fragmented information, disconnected systems and a lack of shared ways of working make this difficult.

Fragmented information makes it harder to deliver the right care.

One proven digital solution for multi-agency care

Whatever your multi-agency programme, you need a proven, flexible digital solution that connects teams, helps you coordinate care and integrates with your existing clinical system.

〝We were looking for a solution that could do much more than simply manage referrals. Our ambition was to create a secure, collaborative platform that provides a digital front door to local services, supports multidisciplinary team working, and enables information to write into the clinical record to improve continuity of care. As Integrated Neighbourhood Teams continue to develop, it was important that the solution could support not only our Social Prescribing service but our wider Personalised Care Team, while also facilitating joined-up working across primary care, community, local authority and voluntary sector partners.〞

Bradley HoughDigital & Transformation Lead, North Arden and Nuneaton & Bedworth Primary Care Networks

Track record

Referrals managed every year

Real-time auto updates per month between RIVIAM and TPP SystmOne™

Return per £1.00 invested. BaNES Community Wellbeing Hub independent business case review found it’s delivering £4.00 per £1.00 invested, this includes social and direct benefits to health and social care with an ‘optimism bias’ of 70%

Coordinate care across organisations

By providing one referral front door and shared workflows, caseloads, appointments, tasks and outcomes, RIVIAM's Muli-agency Care Coordination Hub gives teams a holistic view of each person's care and support, regardless of which organisation employs them.

This helps professionals work more effectively, reduces duplication and supports joined-up, personalised care that improves outcomes and helps people stay healthier and independent for longer.

Better continuity of care through seamless integration

Relevant patient information and outcomes can be automatically updated to your existing clinical system, reducing duplicate data entry and keeping records up to date.

Flexible to your needs. Secure by design

You can configure the hub around your programme, adapting to your services, teams and ways of working.

Built in role-based access controls enable professionals to collaborate securely across teams and organisations, ensuring they only see the information they are authorised to access.

Built on RIVIAM’s existing secure platform

The hub builds on RIVIAM’s established referral management and care co-ordination digital services, used by the NHS and social care everyday.

One hub for everyone who supports the person, whichever organisation employs them.

〝Neighbourhood health can only succeed when Primary Care, community services, Local Authorities and the voluntary sector work together around the person. But joined-up care shouldn't mean every organisation needs another system or has to enter the same information twice. What’s been missing is the RIVIAM platform that actually supports the multi agency work and transparency: the referral in, the caseload, the diary, the tasks and the update back to the GP record. That’s what our hub is built to do. It works alongside the clinical systems you already use, not in competition with them. And because it's built on RIVIAM's established referral management platform, already trusted by the NHS, organisations can benefit from proven technology rather than starting from scratch.〞

Paul Targett,CEO and Co-founder of RIVIAM

Seamless NHS integration for better continuity of care

RIVIAM integrates with NHS national services, including CIS2 and the Personal Demographics Service (PDS), and clinical systems including EMIS Web, TPP SystmOne and Access Rio.

RIVIAM's Multi-agency Care Coordination Hub - Referrals overview. All data shown in this image is test data.

Features and benefits

RIVIAM isn't a standalone solution for Social Prescribing, WorkWell or another individual service, but a flexible platform that can support multiple programmes and teams working together, with data sharing designed for cross-organisation use.
Built on a referral platform the NHS uses 24/7.
Benefits
Supports a multi-agency network with a NHS trusted case system integrated with existing clinical systems.
RIVIAM connects to national NHS services and the GP record, so information is entered once and then shared.
Staff sign in with their NHS Care Identity (CIS2). A person's demographic details are added automatically via the Personal Demographics Service (PDS).
Patient information is read directly from the clinical record and consultations are written back, dated and coded. Write-backs are part of the consultation workflow within the hub, not a separate task. You agree the clinical codes with us. Staff can see what was sent and resend if needed.
Benefits
Joined-up care across organisations and reduced administration.
No retyping or switching systems and fewer errors in capturing a person's details.
A single, smart configurable referral form supports a request for multiple care services in one instance. Form can be opened in a browser or from the clinical system.
Referrers can sign in with their NHS Care Identity (CIS2).
Personal details complete automatically from PDS.
Benefits
Accessible, user-friendly experience where it's easy to see service criteria and refer to multiple services in one go.
Less data entry for referrers and better-quality information received, reducing follow up administration.
No duplicate referral forms when a patient needs more than one service.
Everything about a case sits in one quick view linked with a record: referral; documents, notes, warnings, flags and history, with an alert when a new referral arrives.
Each service or team can have its own step by step workflow pathway, with a RAG dashboard providing at a glance visibility of progress, priorities and where action is needed. A journal records who viewed and changed what.
Cases can be allocated to a caseworker in one step. Discharged cases can be reopened if someone needs further support.
Benefits
One consistent, efficient way to manage care from referral and triage through to outcomes, with clear visibility of team activity and priorities to help manage demand and backlogs.
Everyone supporting a person works from the same record, whichever organisation employs them.
Tasks can be assigned to a user, pathway, step or case and linked to a patient's record so the follow-up call or the six-month ONS4 review are created, assigned and managed across the whole team.
Supports templates, prioritisation, due dates, status tracking, notes and activity, with a full audit trail.
Benefits
Replaces separate lists and manual workarounds, giving teams clear visibility of what needs to happen, when and who is responsible, helping manage workloads, keep care moving and ensure nothing falls through the gaps.
Create a list of patients and their cases for review, so teams and MDTs can discuss care status, record notes and assign tasks together in one shared list view.
Supports templates, prioritisation, due dates, status tracking, notes and activity, with a full audit trail.
Tracks the full care journey, including actions, progress and updates between meetings.
Benefits
Brings MDT information, updates and decisions together in one place, enabling faster joint decision-making, clearer accountability and more efficient care coordination. Teams know who is doing what, when and for whom, reducing duplication.
One shared diary to manage appointments and services, with caseworkers able to view their own and the wider team's schedules. This is not a scheduling 'add on', the hub acts as a master diary.
Appointments linked to patient cases, with consultation records automatically created at the booked time.
Flexible appointment management, with adjustable appointment lengths and ability to move entries, reschedule and cancel appointments. Outlook calendar integration and video appointments.
Benefits
Simpler day-to-day scheduling with better visibility of workloads and capacity for professionals and across the whole team, useful for reporting.
One flexible, reliable diary that reduces duplicate data entry. There's no need to keep another calendar.
An integrated hub Service Directory enables teams to find appropriate local services as part of the person's care journey.
A public facing version gives citizens and professionals easy access to information about available local support.
People search by what they need and how far they can travel, and listings can be shared with other local systems via the Open Referral UK standard.
It's easy to bespoke settings such as for text size, style and colours.
New functionality will enable customers and providers to update and manage their own listings.
Benefits
A digital front door to local health and wellbeing services, all in one place. Each service shows who it’s for and how to access it.
Easy to filter by type of support, or find what’s near the person. Staff can find and refer to services without leaving RIVIAM.
Built to Open Referral UK, so directory data can be shared.
Capture, track and measure outcomes over time (eg ONS4) , with clear, easy to read graphs and data downloads for reporting.
Scores sit against the person’s case, so the starting point and later reviews can be seen together, and progress assessed.
Schedule outcome capture using tasks, so nothing gets forgotten.
Benefits
Demonstrate the difference support has made to a person over time, without the need for separate spreadsheets.
Shared dashboards show the status of care delivery, with notes and actions recorded in one place.
Live counts of referrals and cases by RAG status show team leads where work is building up.
Customer self reporting enables activity, appointment and outcome data captured in the hub to be captured and analysed.
Benefits
Collaborating organisations stay aligned and can act quickly on what needs attention.
Accurate activity and outcome data for contract reporting and service planning.

What sets RIVIAM apart

RIVIAM delivers all the core functionality needed to support programmes for multi-disciplinary care coordination. Additional features make our hub more flexible and distinct from other digital providers.

A full Diary and Task list, built into the hub rather than added on. And there are fewer clicks so everyday tasks are designed to take as few steps as possible.
A Service Directory where it's easier to find the right service quickly and refer in the same place.
Flexible and configurable; we work closely with every customer, before and after go-live.

RIVIAM's Multi-agency Care Coordination Hub - Diary view. All data shown in this image is test data.

Security first

Users can only access cases and patient records managed by their own organisation. They can still see a clear overview of a person’s care with a quick snapshot of related referrals handled by other organisations.

This ensures patient data is protected while enabling seamless care co-ordination across multiple organisations and teams.

RIVIAM's Multi-agency Care Coordination Hub - Patient caseload overview including: tasks, services and timeline. All data shown in this image is test data.

See the impact

〝Working with RIVIAM has been a genuinely collaborative experience. Their established track record of connecting health, care and voluntary sector organisations gave us confidence that we could co-design a solution that meets our current needs, whilst supporting our long term vision. The launch of the hub is an important step towards better co-ordinated care, improved visibility of patient outcomes, and a more connected system of support for our patient population.〞

Bradley HoughDigital & Transformation Lead, North Arden and Nuneaton & Bedworth Primary Care Networks

Sara DixonLocality Manager, People and Policy BaNES Council

Break down silos and enable joined-up working

You are at the heart of the shift to more preventative, community-based multi-agency care. With RIVIAM, you'll have one care hub and a clearer patient picture.