Collaborate Across the Care Continuum – Resource Library
- ACO Beneficiary Engagement Toolkit
- Association of a Care Coordination Model with Health Care Costs and Utilization
- Breaking Down the Basics of Population Health Management
- Critical Lessons from High-Value Oncology Practices
- Delivering On Accountable Care: Lessons from A Behavioral Health Program To Improve Access And Outcomes
- Factors That Distinguish High-Performing Accountable Care Organizations in the Medicare Shared Savings Program
- Housing, Transportation, And Food: How ACOs Seek to Improve Population Health By Addressing Nonmedical Needs Of Patients
- Implementing a Hybrid Approach to Select Patients for Care Management: Variations Across Practices
- Medicaid Managed Care for Members with Mental Health Conditions and/or substance use disorders: Integrating Benefits and Care
- Robert Wood Johnson Foundation: ACO Evaluation
- The Characteristics of Physician Practices Joining the Early ACOs: Looking Back to Look Forward
The following resource(s) may be of value:
- Beyond the EHR: Shifting payment models call for hospital investment in new technology areas
- Cardiac Rehab Improves Health, But Cost and Access Issues Complicate Success
- Commonwealth Fund Spotlights State-Level Health Disparities
- Findings from the Deloitte 2019 Health Care CEO Perspectives Study: Unique insights from industry leaders
Health Value Atlas
Collaboration
Collaborate across the Care Continuum
Organizational capabilities related to collaborating with external medical providers
Note: Some organizational capabilities cross over to other domains. There may also be some degree of capability overlap with Health Equity Advancement, Continuous Quality Improvement, and Health Information Technology domains.
Manage provider relationships
Build and manage provider relationships
Exercise patient stewardship
Exercise active patient stewardship and attribution
Identify intervention candidates
Identify patient candidates for targeted interventions
Automate data access
Automate timely access to data within and outside the organization
Communicate with providers
Communicate proactively with external providers
Track patient progress
Track patient movement through the care continuum
Facilitate transportation
Address patients’ transportation barriers to care
Support external providers
Provide resources and support to external provider partners
Standardize collaboration
Standardize collaborative care processes
Distribute savings and losses
Distribute savings and losses fairly among provider partners
Execute care plans
Create and execute collaborative care plans
Manage referrals
Manage patient referrals and appointments between providers
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