THE WELLNESS SOLUTION FOR COMMUNITIES OCHI is a platform designed to support an Integrated Community Health Model by serving as a system data collection tool between Healthcare Providers, Community Based Organizations, and Social Service Organizations. CUSTOM PROGRAMS FOR CARE MANAGEMENT OCHI engages local CBOs, including YMCAs and fitness centers, to provide both exercise and health coaching while tracking established care plans of those suffering chronic conditions. Participant data is routinely collected to monitor improvement and is digitally transferred to the treating physician. Collaborative Care & Data Sharing - Allowing patient data collection for Clinician based Wellness Services - Automating the creation of Patient Care Plans - Facilitating Digital Referrals to CBOs offering Evidenced Based Wellness Programs - Integrating Providers and CBOs into Social Service Networks - Supporting HIPAA compliant data integration to Provider EHR Physician Referrals into Appropiate CBO Programs - Weight Loss and Management - Blood Pressure Management - Diabetes Prevention and Management - Falls Prevention Management - Depression Intervention and Management