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Case Study

Driving value with integrated care coordination

Learn how provider organizations can drive value with integrated care coordination.
Doctor reviews patient data on computer
Case Study

Driving value with integrated care coordination

Learn how provider organizations can drive value with integrated care coordination.

Learn more about our value-based readiness model

aligned business model components

The transformation to value-based programs involves many facets of the provider organization, from your revenue and physician compensation models to your clinical and operational workflows, documentation, analytics, and reporting.  With such a widespread impact, Baker Tilly recommends establishing a value-based transformation steering committee with representation from all impacted stakeholder groups – finance, administration, physicians, nursing, care coordination, case management, information technology etc. – to inform, guide, and champion the change throughout the entire organization. The steering committee serves as the overall transformation management committee, with project-based operational committees designing and implementing the day-to-day activities of specific initiatives within the overall transformation program.

As your steering committee moves toward value-based care (VBC) arrangements, an early success factor is establishing an integrated model of care coordination across the continuum – breaking down historical silos such as ED, inpatient, outpatient, home health, etc. – in order to drive a patient and outcome-focused approach to care delivery and management that drives quality performance. An integrated care model supports and engages the patient beyond the point-of-care, ensuring higher compliance and increased positive outcomes.

The Four Pillars

Baker Tilly’s approach to transforming care coordination into an integrated program across the continuum consists of defining and implementing four pillars that support the new function: Vision, Structure, Protocols, Team.


Define an approach that aligns care coordination with patient needs across the organization and ties directly to strategic goals.

  • Identify the managed population(s): top DRGs by volume, readmissions, high risk and rising risk scores (scores that have a Social Determinants of Health (SDoH) component).
  • Determine program capacity: how many patients can be managed at the inception of the program based on patient population needs and organizational resources.
  • Define the goal of the program: align program goal to the organization’s strategic objectives such as reduce readmissions, improve health of the population, engage all targeted population patients using continuum of care, etc.
  • Example: The department will manage all high risk or moderate risk patients as determined by the use of a valid stratification/assessment tool integrated into clinical documentation.


Develop a structure for the program that can support the vision and goals.

  • Develop care protocols based on best current evidence for timing of follow-up calls/primary/chronic care visits, etc.
  • Define a new workflow to support the cross-continuum integration.  For example, the workflow should include first patient interaction within 48 hours of admission, daily rounds with the care delivery team, patient visit for medication management and expectations for follow-up, and schedule a clinic/PCP appointment prior to discharge.
  • Establish effective working relationships between the care coordination team and the inpatient practitioners, the post-discharge providers, and patient family/care-givers.
  • Care Coordination team notified of patients daily based on admission diagnosis, risk stratification or other triggers as reported by the EHR.
  • Stratify patients for disease-based risk and socio-economic risk factors (SDoH).
  • Assign patients to practitioners for follow-up based on need.  For example, disease-based primarily assigned to RNs, socio-economic (SDoH) to social workers, and complex medical/high risk assigned to an Advanced Practice Nurse (APN).
  • Define the expectations of follow-up based on patient need as determined by discharge data regarding top DRGs, readmissions, and penalties.


Revise care protocols to support cross-continuum care needs.

  • Base all protocols and processes on data-driven need and data-evaluated outcomes.
  • All criteria and protocols leverage the best current evidence appropriate for the patient population.
  • Policies will address education of all patients and identified caregivers including patient understanding of illness, medication management, and chronic disease management.


  • Roles necessary in an integrated care coordination program:  Director/Manager, Clinical Pharmacist (PharmD), RN Care Coordinators, Community Navigators, Advanced Practice Nurse (APN)s, Physician Advisors, Social Worker (MSW).
  • Create job descriptions for each team member.
  • Social Workers and Community Navigators push capability closer to home and positively affect SDoH issues in particular.
  • A care coordinator can effectively manage a caseload of 75-125 patients, supported as needed by other team members. Ratios also depend on the processes and expectations (structure) for interaction of care coordinators.
  • Minimum contact timing recommendation:  daily inpatient follow-up with an average 3-5 patients per day per coordinator, telephone contact post-discharge at weekly intervals for next 30 days, followed by monthly contact after that.
  • Actual staffing for the department will depend on the percent breakdown of high risk (high touch) and medium risk (medium touch) patients.
  • In the first stages of the new care coordination program, focus only high or medium touch patients.

Baker Tilly’s strategic approach in action

Baker Tilly’s care coordination transformation approach provides the tools to successfully help your organization prepare for value-based care by building an effective cross-continuum care function that enables better patient outcomes and higher quality performance.

  • Define the vision for the new care coordination function that supports organizational goals and value-based care program performance metrics. For example, your organization’s initial vision is to fully support patients in the top three DRGs from presentation through discharge, follow-up care, ancillary visits, home monitoring and engagement until the condition is resolved. 
  • Craft a structure for care coordination that enables cross-continuum care relationships and breaks down traditional silos of care. In the vision noted above, the care coordination team needs to define a structure that can engage the patient in a specific scenario with the right resource at the right time. The resource pool needs to include physicians, nurses, pharmacists, social workers, and other ancillary providers as needed.
  • Develop evidence-based and data-evaluated protocols for patient care that support your defined target populations and drive effective metric performance.  How will your organization adapt evidence-based protocols to support patients in all potential scenarios? What are the tools and reporting structures that will be used to track the data and measure effectiveness?
  • Build a cross-functional team of nurses, social workers, APNs, and physicians that can effectively enable support of all patient needs. Your vision to support a patient across the continuum means engaging the patient in each scenario with the right resources to guide an manage that patient – Baker Tilly can help you define the scenarios, the structure, the protocols, and the resources you need to be successful with your patients in this new model.
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