WHAT WE DO
Care Coordination Services
The CHESS clinical team delivers care high touch care for the most complex patients. The team is based in a centralized hub that supports multiple practices and providers across multiple organizations. Our Care Coordination Team specializes in:
- Care gap identification and closure
- Annual Wellness Visits
- Transitions of Care Support
- Health Coaching
- Chronic Care Management
Our team has assisted numerous health systems in creating outpatient care coordination teams, driving initiatives that bridge fee-for-service environments to success in value-based contracts.
The Care Coordination team outreached 24% of contracted lives – 5688 acute patients and 894 chronic patients with a total of 21,673 touches in 2018
Saved $1.7 million in previous 8 months by outreach and interventions that prevented ED visits or hospitalizations
All value partners saw a 5-15% increase in AWV completion under CHESS guidance
The Care Coordination team prevents 46 ED/ IP events per month through outreach to patients, identifying issues, and referrals to the CHESS Pharmacy Hub
Clinical Pharmacy Services
Clinical Pharmacy Services provides quality patient care with a centralized medication management service available to providers and patients throughout the CHESS network. CHESS clinical pharmacists specialize in:
• Centralized and Embedded Pharmacy Services
• Medication Assistance Patient Support
• Comprehensive and Targeted Medication Management
• Multi-disciplinary High Utilizer Reviews
• Patient and Provider Education
• Quality Measure Management
• Medical/Pharmacy Benefit Drug Spend Management
CHESS manages over $40 million in medical benefit drug spend within value-based agreements with downside risk.
Providers refer over 400 patients annually to the CHESS Pharmacy Hub.
Supports over 500 cases annually for patients unableto afford prescribed medications, including over$200,000 annually in avoided patient out-of pocket expenses.
Improves quality measure performance for over 150,000 patients in value-based contracts.
Learn about Care Transformation