Facilitate Access to Care Collaborate Across the Care Continuum Manage Financial Outcomes Understand Patient Population Practice Evidence-based Medicine Expand Reach Beyond Care Settings Deliver Patient-centered Care Address Non-medical Factors Adapt to Value Redesign Care Processes 01 Care Access 02 Collaboration 03 Patient-centered Care 04 Expanded Care 05 Evidence-based Medicine 06 Population Analysis 07 Financial Management 08 Non-medical Factors 09 Adapt To Value 10 Care Redesign 10 Care Redesign

Health Value Atlas


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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