WHAT WE DO
Care Coordination Services
The CHESS clinical team delivers 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 5,938 acute patients and 640 chronic patients with a total of 26,360 touches in 2019.
Saved $2.45 million in 2019 by outreach and care coordination 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 41 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 Pharmacy Hub manages over $60 million in medical benefit drug spend within value-based agreements with downside risk.
Providers refer over 500 patients annually to the CHESS Pharmacy Hub.
Supports over 500 cases annually for patients unable to afford prescribed medications, including over $275,000 annually in avoided patient out-of-pocket expenses.
Improves quality measure performance for over 185,000 patients in value-based contracts.
Learn about Care Transformation