Doctor smiles and talks to elderly female patient

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

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.

21,673
TOUCHES

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

$1.7
MILLION

Saved $1.7 million in previous 8 months by outreach and 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
46 EVENTS

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

$40
MILLION

CHESS manages over $40 million in medical benefit drug spend within value-based agreements with downside risk.

400
REFERRALS

Providers refer over 400 patients annually to the CHESS Pharmacy Hub.

$200,000
SAVINGS

Supports over 500 cases annually for patients unableto afford prescribed medications, including over$200,000 annually in avoided patient out-of pocket expenses.

150,000
PATIENTS

Improves quality measure performance for over 150,000 patients in value-based contracts.

Learn about Care Transformation