Epic's Compass Rose transforms care coordination with SDOH tracking
Epic's Compass Rose transforms care coordination with SDOH tracking
Epic's Compass Rose transforms care coordination with SDOH tracking
Modern healthcare has evolved beyond just clinical treatment. It now follows a more holistic model that considers the full picture of a patient's life. Social Determinants of Health (SDoH) are estimated to drive up to 80% of health outcomes, making it just as important to understand a patient's environment as their medical history. Epic Compass Rose was designed to bridge this gap. It brings together care coordination, social health data, and population health management into one unified platform. Connecting previously fragmented records, it helps healthcare organizations better understand patient needs and address the root causes of health disparities. This, in turn, supports improved long-term patient stability. This guide provides a clear overview of Epic Compass Rose, including its features, real-world use cases, and more.
What Is Compass Rose in Epic?
Epic Compass Rose is a coordination module embedded in Epic EHR that manages complex patient care, tracks social determinants of health (SDOH), and streamlines patient coordination.
It is primarily an extension of the Healthy Planet population health suite. It enables providers to build structured care plans, visualize patient support networks (ecomaps), and manage community-based referrals.
What sets it apart from a standard patient chart is its focus on social determinants of health (SDOH), the non-clinical factors that often have the biggest impact on health outcomes:
- Access to food and nutrition
- Stable housing
- Reliable transportation
- Financial security
- Community support systems
These factors are surfaced directly in the patient record, alongside clinical data like vitals and lab results. Care teams can address them proactively, not as an afterthought.
The platform was developed as an extension of Epic Healthy Planet and pulls together functionality from three areas:
- Healthy Planet: Population health management
- Social Care: Community and SDOH tools
- Coordinated Care Management: Care team workflows and case tracking
How Compass Rose Fits Within the Epic Ecosystem
The Compass Rose Epic module is inherently integrated in Epic EHR, not an add-on. It shares data, workflows, and reporting infrastructure with the rest of the Epic system.
That means care managers, social workers, nurses, and physicians all work from the same record. When a care manager screens a patient for food insecurity and generates a community referral, the patient's physician sees it at their next encounter. No duplicate data entry. No system-switching.
What Does the Epic Compass Rose Module Do?
The epic compass rose module is task-driven and organizes patient work into structured workflows that help care teams prioritize, track, and follow through consistently.
Capabilities include:
- SDOH screening: Document social health findings directly in the patient's medical record.
- Program enrollment: Enroll patients in community-based, disease management, or transitional care programs.
- Outreach tracking: manage follow-up tasks with completion metrics and accountability workflows.
- Care plan management: Create and collaborate on care plans with the full care team, including community partners.
- Outcome monitoring: Track intervention results across programs to measure what's actually working.
- Community referrals: Connect patients to social services, food programs, housing support, and transportation resources.
- Transitional care management: Structured post-discharge follow-up protocols that reduce readmission risk.
How Is Epic Compass Rose Built on the National Academy of Medicine Standards
The Epic Compass Rose module is structured around the eight standard SDOH domains published by the National Academy of Medicine. This was a deliberate choice by Epic as it supports industry-wide consistency and improves interoperability across health systems.
Epic has expanded the framework further to cover areas like:
- Transportation access
- Housing stability
- Postpartum depression
Age-specific screening variations are also built in, so content can be tailored for pediatric, adult, or elderly patients. The result is a nationally recognized framework that still leaves room for customization.
Epic Compass Rose and Epic Healthy Planet Integration
To understand Epic Compass Rose fully, you need to understand how it connects with Epic Healthy Planet; the two are designed to work together.
What Is Epic Healthy Planet?
Epic Healthy Planet is Epic's population health management platform. Primary care physicians and care managers access dashboards and run population-level reports pulling in both clinical EHR data and health determinant data for a more complete picture.
For organizations operating within Accountable Care Organizations (ACOs), Healthy Planet is the backbone for meeting quality benchmarks and demonstrating value to payers.
It gives healthcare organizations the tools to manage patient populations:
- Identify at-risk patients before conditions escalate
- Track care gaps across a population
- Measure quality metrics and cost of care
- Use predictive analytics to assign risk scores
- Coordinate care across clinical teams and departments
How Epic Compass Rose and Healthy Planet Work Together
Healthy Planet shows you who needs attention across your population. Compass Rose gives your team the tools to do something about it.
When Healthy Planet identifies a high-risk patient, Compass Rose handles the next step, enrolling them in a care program, assigning tasks to the right team members, documenting every touchpoint, and tracking outcomes over time.
The two platforms share data natively within Epic, so there is no duplication of effort or data silos. Your team can move from population-level insight to individual patient action without leaving the system.
What Is Epic Healthy Planet Link?
Not every organization works within a fully Epic network. For those that partner with community organizations or non-Epic providers, Healthy Planet Link (HPL) fills the gap.
HPL is Epic's web-based portal that extends care coordination capabilities outside the Epic network. Through it, external partners can:
- Access shared patient information
- Send real-time messages to care teams
- Identify and flag care gaps
- Monitor care plans and program progress
- Use custom dashboards to manage their patient caseload
Compass Rose enhances Healthy Planet Link by giving community providers access to medical information, including vitals and lab results, via desktop or mobile, enabling more complete care even outside the hospital walls.
Epic Compass Rose in Specialty Pharmacy
One of the more notable applications is in Epic Compass Rose specialty pharmacy settings. While the platform was built with social work and care management in mind, specialty pharmacy teams have found it to be a strong fit for their workflows.
Before Compass Rose, much of this work lived in spreadsheets or separate tracking systems - making it hard to standardize, audit, or scale.
Specialty pharmacy care is complex; patients on specialty medications typically require:
- Ongoing clinical assessments
- Regular lab monitoring
- Prior authorization management
- Refill coordination
- Side effect tracking and patient education
Real-World Implementation: UC Davis Health
A 2024 study published in Exploratory Research in Clinical and Social Pharmacy documented the first peer-reviewed implementation of Compass Rose in a specialty pharmacy setting, at UC Davis Health.
The team replaced legacy spreadsheet-based tracking with Compass Rose to bring pharmacy care management fully into the EHR. These were the outcomes:
- Standardized workflows across the specialty pharmacy team
- Improved ability to quantify staff performance with documented metrics
- Greater transparency around the care being delivered to each patient
Staff were trained ahead of go-live, with subject matter experts working closely alongside Epic's implementation team to build workflows that reflected real pharmacy practice.
Benefits of Epic Compass Rose to Support Value-Based Care
The shift from fee-for-service to value-based care is changing how health systems approach patient management. Under value-based models, organizations are accountable for outcomes across the entire care journey.
Compass Rose supports this shift in three ways:
- Stay connected between visits: Structured outreach workflows keep care teams engaged with patients outside the clinical setting
- Intervene early: SDOH data and risk stratification help teams identify and act on risk factors before they escalate
- Document impact: care plan tools and outcome tracking create the paper trail needed to demonstrate value to payers and ACOs
Organizations like Accountable Health Partners (AHP) have moved their care management teams onto Compass Rose for exactly these reasons. Their social work and RN care managers use it as their primary documentation platform, with the stated goal of using that data to inform population health priorities over time.
Epic Compass Rose Integration with Non-Epic Systems
Compass Rose works most seamlessly in an all-Epic environment. But most health systems operate with a mix of EHRs, community platforms, payer systems, and third-party tools.
Epic addresses this through Healthy Planet Link and its broader interoperability framework, which supports:
- Payer claims data ingestion
- External patient roster import
- Data exchange with non-Epic EHR systems
- Community platform connectivity
For organizations planning an epic compass rose integration with external platforms, configuration decisions made at the start of implementation have a significant downstream impact. Working with experienced Epic consultants or vendor services members like our website helps ensure those decisions reflect real clinical workflow needs, not just technical specs.
Epic Compass Rose Training and Certification
Getting the most out of Compass Rose depends heavily on the team with Epic Compass Rose certification. The platform is feature-rich, and without proper onboarding, staff often end up using a fraction of what's available or building workarounds that defeat the purpose.
What Does Epic Compass Rose Training Cover?
Epic compass rose training is designed for care management, social work, and clinical teams. Core areas include:
- Chronic Care Management (CCM): Episode management, billing workflows
- Transitional Care Management (TCM): Post-discharge follow-up protocols
- SDOH Screening: Documentation in the patient record
- Program Enrollment: Outreach management and task tracking
- Care Plan Workflows: Provider collaboration and sign-off
- Radar Dashboards: Reporting and population-level tracking
- Community Referrals: Findhelp platform integration
Training is done via the following methods:
- eLearning modules: Self-paced, role-based content
- Instructional videos and handouts: Reference material for post-go-live
- Live practice sessions: Hands-on time in a training environment
- Super-user programs: Designated SMEs in each department who support their colleagues after launch
Timing matters. Most implementation teams recommend distributing training materials at least three months before go-live, with hands-on sessions concentrated in the two weeks immediately before launch.
Is Epic Compass Rose Right for Your Organization?
Consider it a strong organizational fit if you are:
- Running Epic or planning a full Epic implementation
- Transitioning to value-based care and needing structured care management workflows
- Managing complex patient populations with significant social or clinical needs
- Dealing with fragmented care coordination across departments, locations, or external partners
- Operating a specialty pharmacy that needs task-driven case management in the EHR
- Participating in ACOs or payer arrangements requiring quality reporting and care gap tracking
If your team is still working out of spreadsheets or disconnected systems, Compass Rose represents a meaningful step forward, but only if the Epic integration or implementation is done thoughtfully.
A rushed or poorly scoped go-live leads to underutilization, workarounds, and staff frustration. The organizations that get the most out of Compass Rose are the ones that map their workflows before go-live, train their teams properly, and have experienced Epic support throughout the process.
Conclusion
Epic Compass Rose is one of the more practical tools in Epic's suite for organizations serious about care coordination and population health. It connects social care, case management, and health program administration in a way that's grounded in evidence, built on national standards, and deeply embedded in the Epic platform.
The value it delivers, in social work, disease management, transitional care, or specialty pharmacy, comes down to three things: how well it's implemented, how thoroughly staff are trained, and how thoughtfully it connects to existing workflows and data sources. If your team is evaluating Epic Compass Rose or heading into an implementation, working with us can get you to value faster.