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providing online non-downloadable cloud-based software, for use with various computing devices including server, desktop, and laptop computers, tablets, mobile phones, and other handheld devices, that receives event notifications, health data, claims data, social data, human service data, education data, and other information pertaining to a patient's present and historical care to enable program staff at healthcare payers, healthcare providers, managed care organizations, accountable care organizations, community-based organizations, and other service providers to implement outreach, assessments, service needs matching, closed-loop referrals, disease management, and other specialized programs, create and manage daily tasks related to those programs, and evaluate overall program effectiveness