Care Coordination: Closing the Gaps Along the Continuum

Quick Overview

This report outlines how savvy providers are leveraging specialized resources to strengthen coordination and engagement across the care continuum.

Availability: In stock

Pubcode: INTEL0715
Price: $399

It can be a challenge for healthcare providers to think beyond their traditional focus on direct patient care; but with value-based care, CMS readmission penalties, population health initiatives, and other changes on the horizon, it’s becoming critical that they broaden their scope of care to include the post-visit or post-treatment follow-through that is often required for patients to return to and maintain good health. Coordinating care requires information—knowing which patients to focus resources on, which subsequent care steps are appropriate for each patient, the availability and capabilities of the next care provider, and whether the patient has adhered to provider instruction. This report tracks top providers' changing strategies and the essential roles of EHR and specialized coordinators in strengthening the care delivery chain.

  • Find out how OhioHealth is improving post-operative recovery times and reducing readmissions for coronary artery bypass graft and heart valve patients by locating specialized nurse practitioners within select Skilled Nursing Facilities (SNFs).
  • Learn the strategies leading providers are pursuing to forge stronger collaborative links with PCPs.
  • Find out how specialized care coordinators and quality-assurance RNs can help identify ways to save costs, improve quality, and motivate patient engagement.
  • Find out how Sentara's care coordinators act as an essential communication and support link between patients and their PCPs.
  • Gain a better understanding of the impact of ACOs and medical homes on care coordination efforts.
  • Discover how Sentara has improved its ACO-based care coordination efforts by first building support among PCPs, who are more motivated to increase patient engagement.
  • Learn how SSM uses the Milliman Advanced Risk Adjuster to target at-risk patients for support in SSM’s intense care coordination program
  • Learn how OhioHealth is increasing the cardiovascular skills and experience of these select SNFs, enabling them to act as "extended recovery units."
  • Learn more about the negative impact of EHR non-standardization on care coordination.
  • Learn how SSM has expanded the number of physician practices participating in medical homes, thereby improving access to care and care management.
  • Learn how SSM's efforts are resulting in more appropriate use of acute care services and a leveling-off of health plan contribution costs for participating employers.


This month’s report includes:

  • Case studies from OhioHealth, Sentara Healthcare, and SSM Health
  • Analysis and key takeaways from advisors drawn from our HealthLeaders Media Council
  • Recommendations from the HealthLeaders Media research team
  • A meeting guide to share with your organization

You can use this report to:              

  • Track the latest trends in population health
  • Gauge your organization's performance and progress compared to peer organizations
  • Gather insights and advice from industry experts, peer leaders, and the experiences of case study organizations
  • Access discussion questions that can aid your organization in forming strategies for population health


This report, part of HealthLeaders' Intelligence Report Premium series, offers the latest population health strategies from industry peers, including survey results drawn from the HealthLeaders Media Council, an exclusive group of 8,400 healthcare leaders. A new segmentation tool allows you to access more specific, in-depth data by setting, number of beds and sites, net patient revenue, and region.