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

Doctor smiles and talks to elderly female patient

Care Coordination

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.

41,912
TOUCHES

The Care Coordination team outreached 22,001 acute patients and 1,487 chronic patients with a total of 41,912 touches in 2022.

$8.9
MILLION

Saved $8.9 million in 2022 by outreach and care coordination interventions that prevented ED visits or hospitalizations.

5-15%
INCREASE

All value partners saw a 5-15% increase in AWV completion under CHESS guidance.

AVERAGE
42 EVENTS

The Care Coordination team prevents 42 ED/ IP events per month through outreach to patients, identifying issues, and referrals to the CHESS Pharmacy Hub.

Learn about Care Transformation