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 22,001 acute patients and 1,487 chronic patients with a total of 41,912 touches in 2022.
Saved $8.9 million in 2022 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 42 ED/ IP events per month through outreach to patients, identifying issues, and referrals to the CHESS Pharmacy Hub.
Learn about Care Transformation