TEAM of Care

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Challenges: Cost and Quality

ACOs and Clinically Integrated Networks Face Several Challenges and Opportunities

The Big Opportunity: 

Healthcare providers committed to value-based care deserve to be compensated for increasing the quality of care and reducing the cost of care for your patients.

The Big Challenges:

  1. Reducing cost of care.
  2. Increasing quality of care.
  3. Working across a multi-disciplinary TEAM.
  4. Working across a cross-organizational TEAM.

Why are these difficult? Execution

Has your organization put specific plans in place to reduce cost and increase quality of care?

  • Reduce ED Utilization
  • Reduce Hospital Admissions
  • Reduce Chronic Disease Burden
  • Reduce Network Leakage
  • Integrate Multi-Disciplinary Care
  • Integrate Post-Acute Care
  • Increase Patient Access
  • Optimize Team Performance

Addressing the Pain Points: Processes and Programs

TEAM-Win contains a TEAM-Playbook with dozens of best-practice processes.  These processes (or Care Coordination Programs) are sets of specific interventions proven to systematically reduce costs and improve quality of care across a clinically integrated network.  Each TEAM-Playbook is customized to connect your data systems and distribute work to your TEAMs.

Take a look at the list of pain points below – and the multiple TEAM-Playbooks that can help your organization achieve exceptional results. 

Some of the Playbooks that help reduce hospital admissions:

  • High-Risk Patient Management
  • Chronic Condition Management
  • Closed-Loop Referral
  • Annual Wellness Visit Program
  • Encounter Notification Response
  • Post-Discharge Management
  • Post-Acute Facility Integration
  • Patient Goal Management

Some of the Playbooks that help reduce ED Utilization:

  • High-Risk Patient Management
  • Chronic Condition Management
  • Closed-Loop Referral
  • Annual Wellness Visit Program
  • Encounter Notification Response
  • Post-Discharge Management
  • Post-Acute Facility Integration
  • Patient Goal Management
  • Preventative Health Integration

Some of the Playbooks that help reduce costs and improve care through better Chronic Disease Management:

  • Condition Program Enrollment
  • At-Risk Population Registry
  • At-Risk Population Intervention
  • Condition-Specific Key Success Factor
  • Closed-Loop Referral
  • Self-Management Evaluation
  • Deterioration Response Protocol
  • Patient Goal Management

Some of the Playbooks that help reduce costs and improve care through better Post-Acute Facility Integration:

  • Service Selection Program
  • Site Selection Program
  • Integrated Care Planning
  • Integrated Discharge Planning
  • Deterioration Response Protocol
  • Closed-Loop Communication
  • Post-Discharge Management

Some of the Playbooks that help Reduce Network Leakage:

  • Condition Program Enrollment
  • Encounter Notification Response
  • Discharge Planning
  • Transfer Facilitation
  • Closed-Loop Referral
  • Post-Discharge Management
  • Post-Acute Facility Integration

Some of the Playbooks that help improve Quality Measure Performance:

  • Preventative Health Integration
  • Chronic Disease Management
  • Integrated Care Planning
  • Integrated Discharge Planning
  • Deterioration Response Protocol
  • Closed-Loop Communication

TEAM of Care works across the widest possible definition and variety of provider organizations and Clinically Integrated Networks (CINs): Hospitals, health systems, Accountable Care Organizations (ACOs), medical practices, specialty care practices, clinics, community organizations, home care, and post-acute care services.

Challenges & Solutions