Health, Education & Government Healthcare Providers Value-Based Care & Population Health

Care Coordination

Clinical, operational, and financial complexity where patient outcomes, revenue, and compliance all intersect.

Netsmart WellSky Casenet Evolent Health
Inside this journey
  1. Customer Discovery

    Align on desired outcomes (ED and readmission reductions), current care management workflows, data sources, and decision-makers.

    Discovery Questions

    Start Here: Who Are We Talking With?

    • Who will be the primary sponsor and day-to-day champion for this care coordination initiative? Options: VP of Care Management, Population Health Director, CMO/Medical Director, Chief Nursing Officer, Director of Transitions of Care, IT/Integration Lead, Other (please specify)
    • How many full-time care managers (RNs, social workers, CHWs) are actively managing high‑risk panels today? Options: 1–5, 6–15, 16–30, 31–75, 76+
    • Describe your current care management team structure and handoffs (who owns admission, discharge, follow-up, community referrals)?
    • Which of the following best describes your accountability model for ED visits and readmissions? Options: At-risk via shared savings/total cost of care, Partial risk for specific populations, Fee-for-service with quality incentives, Not currently at risk, Unsure
    • From your perspective, what's the single biggest priority for your team right now (pick one)? Options: Reduce ED visits, Reduce 30-day readmissions, Improve care transitions, Lower total cost of care, Improve patient experience, Meet payer contract metrics, Other

    What Would a Real Win Feel Like?

    • Imagine ED visits and readmissions fell by 20% across your highest-risk cohort — what changes would that actually unlock for your team and organization?
    • Which stakeholders would celebrate that result most loudly (and which would be skeptical)? Options: Finance/CFO, CMO/Medical Staff, Care Management, Payers/ACO Partners, Community Partners, Board/Executives, Other
    • How would your success be measured quantitatively? Select all metrics you’d expect us to track. Options: ED visit rate per 1,000, 30-day readmission rate, Total cost of care, Unplanned admissions, Care manager task completion, Patient-reported outcomes, Time-to-first-follow-up post-discharge, Other
    • How soon would you expect to see a meaningful signal from a pilot before you’d consider expanding it? Options: 30 days, 60–90 days, 3–6 months, 6–12 months, Only after 12 months
    • If a pilot delivered the expected outcomes, what organizational changes or investments would you envision next?

    Are We Just Accepting Preventable Deterioration?

    • Which parts of your current workflows most often allow high‑risk patients to fall through the cracks? Options: Discharge follow-up gaps, Incomplete medication reconciliation, Missed social needs referrals, Delayed admission/ED alerts, Inconsistent risk stratification, Other
    • Can you walk me through a recent patient case where a preventable admission or ED visit occurred—what happened and who was involved?
    • How long has that kind of lapse been recurring, and what attempts have you tried to stop it? Options: Less than 6 months, 6–12 months, 1–3 years, 3+ years
    • Which process causes the most frustration for care managers in that scenario (timeliness, information gaps, competing priorities, tech usability, other)? Options: Timeliness of data/alerts, Fragmented patient history, High caseloads, Platform usability, Lack of social determinants info, Other
    • If you had to name one operational change that would stop those slips tomorrow, what would it be?

    The Data You Swear By (and the Data You’re Missing)

    • If asked to produce a single, trusted risk score for a patient today, which data sources would you rely on? Options: EHR (problem list/notes), Claims / adjudicated claims, Admission/ED feeds (ADT), HIE / regional exchanges, Behavioral health systems, Community resource platforms, No single trusted source
    • Which of these data feeds do you currently receive in near-real-time (within 24 hours)? Options: ADT (admit/discharge/transfer), Primary care EHR notifications, Hospital HIE alerts, Claims (monthly/quarterly), Social determinants screenings, Pharmacy fills, None of the above
    • How reliable is patient matching across your systems today (consistent MRN/HICN, partial matches, lots of duplicates)? Options: High — consistent identifiers, Moderate — some manual reconciliation, Low — frequent duplicates/mismatches, Unknown
    • Who in your organization owns data quality and integration (titles/teams)?
    • Would you be able to provide a sample feed (de-identified or real) for a technical proof-of-concept within 30–60 days? Options: Yes — de-identified available, Yes — real feed available, Not without approvals, No

    Who Moves the Needle Around Here?

    • When a change requires new workflows or investment, who has final sign-off — and who needs to be convinced first? Options: CFO/Finance, CMO/Medical Leadership, Chief Nursing Officer, VP Care Management, IT/VP Digital, Board/Executive Committee, Other
    • What committee or governance body oversees value-based care initiatives and data-sharing decisions? Options: Clinical Operations Committee, Value-Based Care Committee, Data Governance Board, None / ad hoc meetings, Other
    • Have you previously approved pilots that required cross-departmental change (yes/no)? If yes, what made those successful? Options: Yes — clear sponsor + ROI, Yes — regulatory/contractual driver, No — haven't had cross-dept pilots, Other
    • Who should be included in a 30‑minute executive briefing to secure pilot approval?
    • What timelines are realistic for procurement and legal review in your organization (from SOW to signature)? Options: 2–4 weeks, 1–2 months, 2–3 months, 3–6 months, Longer

    What Keeps Your Care Managers Awake at Night?

    • Which task consumes most non-clinical time for care managers (documentation, data reconciliation, referrals, outreach, scheduling)? Options: Documentation/charting, Reconciling disparate data, Managing referrals, Outbound outreach/phone work, Tracking social needs, Other
    • How do care managers currently prioritize their daily caseload — algorithm, manual triage, provider referral, or other? Options: Risk score / algorithm, Provider referral, Manual list by acuity, First come/first served, Other
    • What would reduce burnout fastest: fewer patients, better tools, more training, clearer workflows, or something else? Options: Smaller caseloads, Better technology/usability, Role-based training, Clear escalation paths, More community resources, Other
    • Tell us about a time a care manager felt powerless to prevent a poor outcome—what was missing?
    • What kinds of role-based training or decision support have you tried — and which felt effective? Options: EHR training, Workflow playbooks, Simulation/case reviews, On-the-job coaching, None tried, Other

    What Would Convince Finance to Invest?

    • What evidence would change finance’s view of care management from a cost to an investable strategic capability?
    • What baseline metrics (current ED/readmit rates, costs) can you share to help us size potential ROI?
    • Which threshold would make a pilot 'successful' for your leadership (pick a primary outcome)? Options: 10% reduction in ED visits, 20% reduction in readmissions, X dollars saved per 1,000 patients, Improved patient satisfaction score, Workflow adoption by >75% of care managers, Other
    • How comfortable would your finance team be sharing contract-level performance to support joint governance? Options: Very comfortable, Somewhat comfortable, Only aggregated metrics, Not comfortable
    • What cadence and format of reporting do decision-makers prefer during a pilot (weekly dashboard, biweekly review, monthly executive summary)? Options: Weekly dashboards, Biweekly operational reviews, Monthly executive summary, Quarterly analytic deep-dive, Ad-hoc

    What Would Stop a Pilot Before It Starts?

    • What single technical, legal, or operational requirement would immediately block you from running a pilot? Options: Unable to share ADT or claims, Insufficient IT resources, Security/HIPAA concerns, Clinician resistance, Contractual/payer barriers, Other
    • Do you have any existing non-negotiable privacy or data residency rules we should know about? Options: Standard HIPAA — OK with BAAs, State-specific restrictions, No external data sharing allowed, Other / need to check
    • What internal approvals and approximate lead times are needed for data sharing and integrations?
    • If we identified a security or compliance gap, who would be responsible for remediation and what is a realistic SLA? Options: IT Security, Compliance/Privacy Office, Vendor/third-party, Shared responsibility, Other
    • Are there any upcoming organizational events (merger, EHR migration, contract renewal) that could impact project timing? Options: EHR migration, Mergers/acquisitions, Major contract renewals, Budget cycle, None, Other

    If We Deliver One Quick Win, What Should It Be?

    • If we guaranteed one measurable improvement in 90 days, which of the following would earn your team’s trust fastest? Options: Reduced time-to-first-follow-up post-discharge, Higher accuracy in risk alerts, Reduced duplicate records via matching, Faster referral closure to community resources, Improved task completion rates
    • What minimal patient cohort size and inclusion criteria would you prefer for a focused pilot (e.g., top 250 high-risk by claims, recently discharged heart failure patients)?
    • Who should be the pilot’s executive sponsor, operational lead, and technical owner (titles/names)?
    • What would be an acceptable definition of ‘pilot success’ to move to production (be specific: metric, magnitude, timeline)?
    • How would you like us to share early learnings and iterate—weekly huddles, embedded shadowing, or living dashboard? Options: Weekly operational huddles, Embedded daily/weekly shadowing, Live dashboard with alerts, Biweekly synthesis and playbook updates, Other
  2. Solution Experience

    Translate the customer’s context into a shared view of how the platform prevents deterioration and reduces utilization using real patient scenarios.

    Experience Meetings

    • Solution Experience Pre‑Work & Current State Confirmation
    • Consequence & Opportunity Quantification
    • Live Patient Scenario Workshop — Diagnosis → Proof → Validation
    • Future State Definition, Acceptance Criteria & Measurement
    • Decision & Next Steps — Pilot Design, Data Readiness & Governance
    • Establish the measurement plan and baseline values to be used for pilot evaluation.
    • Customer: Provide finance inputs (cost per admission, average length of stay, reimbursement impacts) and any additional utilization data.
    • Seller: Produce a short cohort impact brief quantifying potential savings and utilization reduction scenarios.
    • Seller/Customer: Schedule a follow up if any consequence assumptions require deeper validation.
    • Re‑state Current State & Desired Future State (one sentence each)
    • For each patient case, obtain explicit validation that the platform's intervention would prevent deterioration and reduce utilization.
    • Identify and document any feature/configuration/integration gaps that block the proven future state.
    • Create a short list of follow‑up data or stakeholder validations needed before pilot design.
    • Seller: Deliver annotated scenario decks showing timeline, platform intervention points, and expected avoided events for each patient.
    • Customer: Provide validation responses (agree/disagree) per scenario and any missing clinical context called out during the workshop.
    • Seller: Log configuration or integration gaps and propose mitigation options for the next meeting.
    • Recap Validated Outcomes from Scenarios
    • Agree on a single operational future state sentence that all stakeholders accept.
    • Define clear, measurable acceptance criteria and success signals with owners and data sources identified.
    • Introductions & Meeting Objectives
    • Seller: Produce a one‑page Future State & Measurement Plan including metric definitions and baseline numbers.
    • Customer: Confirm metric owners and provide any additional data access needed for baseline validation.
    • Seller: Prepare a short pilot success dashboard mock that will be used to report outcomes during the pilot.
    • Customer: Deliver data access credentials/sample feeds and sign the pilot data‑sharing checklist.
    • Executive Recap: Current State → Consequence → Future State
    • Align and secure agreement on pilot scope, cohort, timeline and measurable targets.
    • Confirm data‑feed readiness and assign integration/data owners with delivery dates.
    • Obtain explicit go/no‑go decision or a defined path to sign‑off for the pilot.
    • Seller: Produce a Pilot SOW, timeline, and roles matrix for customer review and signature.
    • Seller & Customer: Schedule Pilot Kickoff meeting and identify milestone owners for deployment readiness.
    • A single, agreed one‑sentence current state that all participants can repeat.
    • A prioritized list of 3 patient scenarios and confirmed data extracts for each.
    • A roster of validation stakeholders (clinical, operational, finance) who will attend scenario sessions.
    • Customer: Deliver one‑sentence current state and anonymized data extracts for 3 patient scenarios by the agreed deadline.
    • Customer: Provide list of invited validation stakeholders and their roles.
    • Seller: Prepare a discovery summary and a scenario template mapping required fields to platform inputs.
    • Recap One‑Sentence Current State
    • Agree on baseline utilization and the quantified cost/operational consequences of the current state.
    • Select prioritized cohorts for the Solution Experience and pilot candidate(s).
    • Capture finance/clinical sign‑off on the consequence assumptions or identify items that need follow‑up.
    • Patient Scenario A — Diagnosis (Timeline & Failure Points)
    • Baseline Metrics Presentation
    • Pilot Scope & Cohort Definition
    • Draft One‑Sentence Future State
    • One‑Sentence Current State Readback
    • Map Consequence to Money/Time/Risk
    • Define Acceptance Criteria & Success Signals
    • Evidence Review: Workflows & Data Sources
    • Data & Integration Readiness Review
    • Patient Scenario A — Proof in Platform (Risk, Match, Workflow)
    • Prioritize Patient Cohorts by Impact
    • Patient Scenario A — Validation Check
    • Governance, Privacy & Roles
    • Assign Metric Owners & Governance
    • Impact Owners & Decision Makers
    • Patient Scenario B — Diagnosis & Proof
    • Select & Define Patient Scenarios (Pre‑Work Confirmation)
    • Measurement Plan & Baseline Confirmation
    • Decision & Next Steps (Sign‑off Items)
    • Finance & Clinical Validation Round
    • Patient Scenario C — Edge Case & Community Services
    • Pre‑work Checklist & Deadlines
    • Consensus & Exceptions Log
    • Immediate Next Validation Steps
  3. Solution Scope

    Define integrations, risk stratification tuning, care plan and workflow modules, training, and measurable acceptance criteria.

    Scope Configuration

    • Integrate EHR Data Feeds
    • Ingest and Normalize Claims Data
    • Patient Identity Matching and Merging
    • Deploy Risk Stratification Models
    • Configure Care Plan Templates
    • Activate Task Automation for Care Teams
    • Enable Referral Management
    • Launch Transitions-of-Care Alerting
    • Deploy Patient Outreach (SMS/Voice/Email)
    • Integrate Community Resource Directory
    • Provision Role-Based User Access
    • Deploy Outcome Tracking and Value-Based Care Dashboards

    Scope Questions

    Integrate EHR Data Feeds

    • Do you require real-time (ADT/FHIR) feeds, near‑real‑time, or daily/batch ingest for EHR data? Options: Real-time/Streaming, Near-real-time (hourly), Daily/Batch, Other
    • Which EHR vendors and number of unique instances/sites should be integrated?
    • What clinical data domains must be ingested (select all that apply)? Options: Problem list/Diagnoses, Medications, Allergies, Labs/Results, Orders, Progress notes/encounters, Vitals, Immunizations
    • Which exchange standards or interfaces are preferred/available (e.g., FHIR, HL7v2 ADT, CCDA, bespoke API)? Options: FHIR (R4), HL7 v2 ADT, CCD/CCDA, Custom API, Other
    • Do you have existing integration endpoints or an integration partner (e.g., HIE, middleware)? If yes, list contacts and endpoints. Options: Yes, No
    • What is the expected daily patient/event volume for EHR feeds (estimate) Options: <100 events/day, 100-1,000 events/day, 1,000-10,000 events/day, >10,000 events/day
    • Are there environment requirements (sandbox/test instance, PHI controls, IP allowlists) or go/no-go security checks we should plan for? Options: Yes, No

    Ingest and Normalize Claims Data

    • Which types of claims do you need ingested (select all that apply)? Options: Medical/Institutional, Professional/Physician, Pharmacy, Dental, Other
    • What formats and frequency are your claims files (e.g., 837/EDI, adjudicated extracts, monthly feeder)? Options: 837/EDI, Adjudicated CSV/Flat file, Monthly batches, Real-time EDI, Other
    • Do you have a preferred claims normalization/terminology standard (e.g., CPT/HCPCS mapping, NPI handling, standardized diagnosis mapping)? Options: Yes, No
    • What is your expected monthly claims volume (number of claims lines)? Options: <50k, 50k-250k, 250k-1M, >1M
    • Are there payer-specific business rules or adjudication fields we must preserve or map? Options: Yes, No
    • Do you require linkage between claims and clinical records for the same patient cohorts (describe matching strategy if known)? Options: Yes, No
    • Do you need historical claims backfill and if so, how many months/years? Options: None, 6 months, 12 months, 24+ months, Other

    Patient Identity Matching and Merging

    • Which data sources will be used for matching (select all that apply)? Options: EHR(s), Claims, HIE/ADT feeds, External master patient index (MPI), Other
    • Do you prefer deterministic matching, probabilistic matching, or a hybrid approach? Options: Deterministic, Probabilistic, Hybrid, Unsure - recommend assessment
    • What acceptable match confidence threshold (e.g., % or score) do you want for automatic merges vs manual review? Options: High (auto‑merge only high confidence), Medium (auto‑merge with review queue), Low (manual review preferred), Unsure
    • Do you require a manual reconciliation UI/workflow for duplicates and suspected merges? Options: Yes, No
    • Are there specific identifiers to prioritize (e.g., MRN, SSN, DOB+Name+Address)?
    • Do patient consent/privacy rules affect the ability to merge or share records across systems? Options: Yes, No, Unknown — legal review required
    • What is your current duplicate rate or known identity match error rate (estimate)? Options: <1%, 1-5%, 5-15%, >15%, Unknown

    Deploy Risk Stratification Models

    • Which risk models do you plan to deploy (select all that apply)? Options: 30-day readmission, ED utilization risk, High-cost prediction, Clinical deterioration, Custom/cohort-specific models
    • Would you like to use our out-of-the-box models, have them tuned to your data, or build custom models? Options: Use OOTB models, Tune OOTB to local data, Build custom model, Undecided — need recommendation
    • Do you have labeled historical outcomes (e.g., readmissions, ED visits) to support calibration and validation? Options: Yes — available, Partially available, No — not available
    • What cadence is required for risk scoring (real-time on event, nightly batch, weekly)? Options: Real-time/event-driven, Hourly, Daily, Weekly
    • Which performance metrics are required for acceptance (AUC, calibration, PPV/NPV, lift)? Options: AUC/ROC, Calibration, PPV/NPV, Lift/decile, Other
    • Are there population cohorts or segmentation rules (e.g., Medicaid, dual-eligibles, COPD) for which separate models are needed? Options: Yes, No
    • Who will own model governance and periodic maintenance (data science team, vendor, joint)? Options: Customer-owned, Vendor-owned, Joint ownership, Undecided

    Configure Care Plan Templates

    • Which clinical conditions or cohorts need templated care plans (select all that apply)? Options: CHF/Heart Failure, COPD, Diabetes, Post-discharge/Transitions, Complex multimorbidity, Behavioral health, Other
    • What components must each care plan include (goals, tasks, education, SDOH interventions, referral actions)? Options: Goals, Tasks/To-dos, Patient education, Referrals, SDOH interventions, Monitoring metrics
    • Do care plans need role-based task assignments and escalation rules? Options: Yes, No
    • Should care plans be patient-facing (patient portal or printable summaries)? Options: Yes — patient-facing required, Optional, No — clinician only
    • Do you require localized language/reading-level variants for patient materials? Options: Yes — multiple languages, Yes — reading-level only, No
    • Will care plan templates require clinical governance approval/versioning workflows before publishing? Options: Yes, No, Unsure
    • Do you want templates mapped to billing or quality measure codes for reporting? Options: Yes, No

    Activate Task Automation for Care Teams

    • Which triggers should create automated tasks (select up to all that apply)? Options: Risk score threshold crossed, Discharge event, Missed appointment, New referral, Social needs screen positive, Other
    • How should tasks be routed (role-based, named user, team queue, round-robin)? Options: Team queue, Role-based, Named user, Round-robin, Other
    • What SLA or expected resolution times should be enforced for critical task types? Options: Same day, 24-48 hours, 72 hours, Custom
    • Are notifications for new/overdue tasks required via email, in-app, SMS, or EHR inbox? Options: Email, In-app, SMS, EHR inbox, Other
    • Do you require audit trails and reporting on task completion, reassignment, and outcomes? Options: Yes, No
    • Should tasks be able to create follow-up tasks automatically (chained workflows)? Options: Yes, No
    • Will task automation need to integrate with external systems (EHR tasks, telephony, scheduling)? If yes, list systems. Options: Yes, No

    Enable Referral Management

    • Do you track both internal and external referrals today or only internal? Options: Internal only, External only, Both, Not currently tracking
    • What referral statuses and lifecycle steps should be supported (e.g., requested, accepted, scheduled, completed)?
    • Do you require automatic matching to providers based on specialty, insurance, geography, or network status? Options: Yes, No
    • Should referral outcomes feed into outcome dashboards (e.g., referral completed, no-show, service provided)? Options: Yes, No
    • Do you have an existing provider directory to integrate or do you need one provisioned/curated? Options: Existing directory — integrate, Need vendor-provided directory, Hybrid
    • Are authorizations/pre-certifications part of the referral workflow that must be tracked? Options: Yes, No
    • Do you require patient-facing referral notifications and scheduling coordination (two-way communication)? Options: Yes, No

    Launch Transitions-of-Care Alerting

    • Which transition events should generate alerts (select all that apply)? Options: ED arrival/visit, ED discharge, Inpatient admission, Inpatient discharge, SNF/PA admission/discharge, Observation status
    • What is the maximum acceptable latency for alerts from event to care-team notification? Options: Within 5 minutes, Within 30 minutes, Within 2 hours, Same day
    • What feed source will provide transition events (HIE ADT, hospital EHR ADT, claims/encounter feed)? Options: HIE/Health System ADT, Hospital EHR ADT, Claims/Encounter, Other
    • Who should receive alerts and how (care manager, primary care partner, team inbox, escalation list)? Options: Assigned care manager, Primary care provider, Team queue/inbox, Escalation list, Other
    • What key data elements must be included in each alert (meds on discharge, discharge diagnosis, follow-up appointment info)?
    • Do you require automatic task creation or care plan changes triggered by transitions? Options: Yes — auto task creation, Yes — modify care plan, No — manual
    • Are there consent or privacy constraints for alert distribution across organizations? Options: Yes, No, Unknown — legal review needed

    Deploy Patient Outreach (SMS/Voice/Email)

    • Which outreach channels do you want to enable (select all that apply)? Options: SMS/Text, Automated Voice (IVR), Email, In-app messaging, Patient portal messaging
    • Do you have consent/opt-in rules and language preferences to enforce for outreach? Options: Yes — ready to provide, Yes — need help defining, No
    • Is two-way/respondable messaging required (patient can reply and messages route to care team)? Options: Yes, No
    • What message volume and peak throughput should we plan for (messages/month)? Options: <1k/mo, 1k-10k/mo, 10k-100k/mo, >100k/mo
  4. Mutual Commit

    Finalize commercial terms, data‑sharing and privacy requirements, success metrics, and governance for outcome accountability.

    Agreement Modules

    • Non-Disclosure Agreement (NDA)
    • Master Services Agreement (MSA)
    • Statement of Work (SOW)
    • Commercial Terms & Pricing Schedule
    • Payment Schedule & Billing Terms
    • Business Associate Agreement (BAA)
    • Data Use / Data Sharing Agreement (DUA/DSA)
    • Data Processing Agreement (DPA) & Privacy Addendum
    • Security & Compliance Exhibit
    • Governance & Success Metrics Charter
    • Outcomes-Based / Risk-Sharing Addendum
    • Acceptance Criteria & Go‑Live Signoff
    • Implementation Schedule & Milestone Signoff
    • Change Order & Scope Management
    • Termination, Offboarding & Data Return Plan
    • Third‑Party Integrations & API Access Agreement
    • Patient Consent & Opt‑In/Opt‑Out Strategy
    • Insurance, Indemnity & Liability Exhibit
    • Training, Support & SLA Agreement
    • Regulatory Attestation & Audit Rights
  5. Deployment

    Operationalize rollout with readiness checks, enablement, and outcome validation.

    1. Pre-Deployment Readiness

      Confirm data access, sample feeds, patient matching strategy, system owners, and HIPAA/security controls before build.

      Readiness Questions

      Start Here: Who You Are and What Success Looks Like

      • What's your role and primary responsibility for care management outcomes? Options: VP of Care Management, Director, Population Health, ACO/Value-Based Care Lead, Clinical Operations Lead, CMO/CIO/Other Executive, Other
      • Are you accountable to value-based contracts that include financial risk for ED visits or readmissions? Options: Yes - downside risk, Yes - shared savings only, We're at-risk for other measures, No, but leadership is asking for outcome improvements, No
      • What specific ED or 30‑day readmission reduction targets have you been asked to deliver (give % or raw numbers)?
      • Approximately how many attributed or high-risk patients does your team actively manage today? Options: <500, 500–2,499, 2,500–9,999, 10,000+
      • Which KPIs does your executive team use to judge care management success? Options: ED visit rate, 30‑day readmission rate, Total cost of care, Care gap closure, Patient engagement/experience, Avoidable utilization per member, Other

      Are We Settling for Band‑Aids?

      • What would it mean for your program if most avoidable hospitalizations are driven by fragmented data and handoffs—not clinical judgment? Options: Completely plausible and common, Somewhat plausible, Unlikely, Unsure
      • Describe your current transitions-of-care workflow from inpatient discharge to follow‑up—who does what and when?
      • Which tools do care managers rely on daily to track patients and tasks? Options: Primary EHR, Secondary EHR(s), Payer portals, HIE portal, Spreadsheets, In‑house case management tool, Care coordination platform, Phone/SMS/outreach tools, Other
      • How often do care managers get actionable notifications (ED visit, discharge, high-risk event) in a timeframe that allows intervention? Options: Real-time or within 1 hour, Same day, Daily batch, Weekly or less, Never
      • How does this current setup make your team feel—overwhelmed, reactive, proud, or something else? Share a short example.

      Which Data Blind Spots Are Costing You Patients?

      • If a single missing feed could prevent a cluster of avoidable readmissions, which feed would you bet on? Options: ADT/encounter alerts, Claims (medical/behavioral/pharmacy), EHR CCD/C-CDA summaries, Lab results, Behavioral health records, Home health/PA/LTC data, Community/social services/SDOH, We don't know / unsure
      • Which of these data sources do you currently ingest into any system? Select all that apply. Options: Real-time ADT/alerts, Claims (payer extracts), EHR clinical extracts, HIE feeds, Pharmacy data, Social determinants/Community resource data, Patient-generated data, None of the above
      • Can you provide a sample feed or example record today for one or more of those sources? Options: Yes — live feed available, Yes — sample extract available, Planned within 30–90 days, Not available
      • What percentage of patient records reliably match across your systems with your current patient matching approach? Options: >95%, 85–95%, 70–84%, <70%, Don't know
      • Tell us about a recent patient who slipped through the cracks because of missing data or a matching error—what happened and what was the impact?

      Who's Holding the Keys — and Will They Share Them?

      • How likely is it that a critical system owner (EHR team, finance, legal, HIE) could block data-sharing required for deployment? Options: Very likely, Somewhat likely, Unlikely, Already committed to share
      • List the key stakeholders and system owners we need buy‑in from (role, team, and how they influence the decision).
      • What are the primary objections you typically hear from those stakeholders (security/privacy, cost, workflow disruption, ROI timeline, other)? Options: Security/Privacy, Cost/Budget, Workflow disruption, Technical complexity, ROI timeline/measurement, Patient consent concerns, Other
      • Do you have an established data governance body, standard DSA/BAA templates, or specific legal requirements we must meet? Options: Governance committee in place, Standard BAA/DSA templates available, Legal reviews required case-by-case, No formal governance yet
      • What internal approval steps typically slow data-sharing decisions, and how long do those gates usually take (weeks/months)?

      How Confident Are You in Your Risk Signals?

      • How often do your 'highest-risk' lists produce false positives or miss patients who subsequently land in the ED? Options: Regularly, Occasionally, Rarely, Unknown / we haven't measured
      • Which risk stratification approaches do you use today? Options: Internal rule-based model, Claims-based vendor model, EHR-built risk scores, Commercial ML model, Hybrid approach, We don't have a formal model
      • Which performance metrics do you actively track for your models (AUC, PPV, recall, calibration, etc.)? Options: AUC/ROC, PPV/Precision, Sensitivity/Recall, Calibration (observed vs predicted), Lift/deciles, We do not track model metrics
      • Have you run local calibration or tuning of models for your population in the last 12 months? Options: Yes — ongoing process, Yes — one-time effort, Planned in next 90 days, No
      • If provided a retrospective sample of risk scores, can you run validation against labeled outcomes (ED visits/readmissions) within your environment? Options: Yes — readily available, Yes — with time from IT/data team, No — not currently possible
      • How do you prioritize between reducing false positives (care manager burden) versus false negatives (missed patients)?

      Imagine a Week Where No One Falls Through the Cracks

      • If you could reduce avoidable ED visits by 25% in six months, what would be the single biggest change in your organization?
      • Which patient cohorts would you prioritize for an initial pilot? Options: Frequent ED users, 30‑day readmitters, CHF/COPD patients, Dual-eligibles, High-cost complex chronic patients, Behavioral health + medical comorbidity, Other
      • Which success metrics would convince finance and leadership to scale the program? Options: ED visit reduction, 30‑day readmission reduction, Total cost of care reduction, ROI within 12 months, Improved patient satisfaction, Reduced avoidable inpatient days
      • If the platform delivered consistent, actionable outreach lists and timely alerts, how would your care managers' day-to-day work change? Give one concrete example.
      • Who would be your executive sponsor(s) for a successful pilot and how would they want to see early wins presented?

      What Would Make Deployment Acceptable — Not Just Possible?

      • What single security or privacy concern would cause you to halt a deployment the day before launch? Options: No signed BAA, No SOC2 Type II/attestation, Lack of encryption at rest/transit, Unclear data segregation/multi‑tenant controls, Other
      • Which certifications or security controls must we demonstrate before you can begin integration? Options: HIPAA BAA, SOC2 Type II, ISO 27001, Pen-test results/vulnerability scans, Encryption at rest & in transit, Role-based access controls / SSO, Audit logging/forensics
      • Which integration methods do you prefer or require (select all that apply)? Options: FHIR APIs, EHR vendor-specific APIs, HIE/ADTs, SFTP/flat files, VPN/on‑prem connector, Payer extract feeds, Other
      • Who will own the day‑to‑day integration and vendor coordination on your side (IT, interoperability team, HIE, clinical ops)? Options: Internal IT/Integration team, Interoperability/HIE team, Clinical Ops/Care Management, Third‑party integrator, Other
      • For user acceptance testing (UAT), what sample patient volume and test cases would you expect to validate data fidelity and workflows?

      Small Commitments That Unlock Progress

      • Which of the following are you willing to commit to this quarter to materially reduce deployment friction? Options: Provide sample feed(s) and credentials, Identify pilot cohort and clinical champions, Allocate 0.5 FTE for integration/testing, Review/approve draft BAA within 30 days, Provide a test environment or synthetic dataset, Other
      • Who will serve as the primary point of contact for project coordination (name, role, email)?
      • What is your ideal target date to begin a pilot? Options: Immediately (1–4 weeks), In 1–3 months, In 3–6 months, 6+ months, Unsure
      • What preliminary acceptance criteria (numeric targets or process milestones) would make a pilot successful in your view?
      • Are there any final concerns, blockers, or people we haven't asked about that could materially affect readiness?
    2. Deployment Enablement

      Execute integrations, configure care models and workflows, deliver role-based training, and track milestone owners.

    3. Validation Checklist

      Verify data fidelity, risk score calibration, workflow adoption, and baseline outcome measurements against acceptance criteria.

      Validation Questions

      Start Here: Tell Us Who You Are and What You Carry

      • What's your title and the team you lead (brief)?
      • Which best describes your organization type? Options: Health system, ACO / clinically integrated network, Managed care plan / MCO, Post-acute network / SNF chain, Other
      • Which populations are you mainly responsible for coordinating? (choose all that apply) Options: Medicare FFS, Medicare Advantage, Medicaid, Commercial, Dual-eligible, High-cost/high-utilizer cohorts, Behavioral health heavy
      • Roughly how many patients are actively managed by your care teams today? Options: <1,000, 1,000–5,000, 5,001–20,000, 20,001–100,000, 100k+
      • What are the top three metrics leadership holds your team accountable for?

      Are You Comfortable With 'Reactive' as Your Default?

      • When an avoidable ED visit or readmission happens, who in your organization usually finds out first? Options: Care manager/team, Primary care provider, Utilization review/case management, Revenue cycle/finance, No one notices until retrospective
      • How often does your team operate in firefighting mode (responding after events) rather than preventing them? Options: Almost always, Often, Sometimes, Rarely
      • Share a recent story where a patient 'fell through the cracks'—what happened, and what stopped you from intervening earlier?
      • How does it feel for your staff when predictable escalations occur—demoralizing, expected, or motivating? Please explain briefly. Options: Demoralizing, Expected/inevitable, Motivating/challenge, Varies by team
      • If you had to name one part of your current process that perpetuates reactivity, what would it be?

      Where Does Your Data Let You Down—and How Often?

      • If your risk scores or alerts were 100% reliable tomorrow, what would your team stop doing?
      • Which data sources do you currently ingest for risk stratification and care planning? (select all that apply) Options: EHR(s), Claims (medical), Claims (pharmacy), HIE/ADTs, Behavioral health systems, Community-based organization (CBO) data, Patient-reported data, None of the above
      • How timely are the critical feeds you depend on (e.g., ADT, claims, labs)? Options: Real-time/near real-time, Daily, Weekly, Monthly or slower, Not available
      • Tell us about your patient matching and deduplication—how confident are you that records represent the same patient across systems? Options: Very confident, Somewhat confident, Low confidence, We don't have a strategy
      • Which single data gap keeps you from acting sooner on the patients who matter most?

      Who Actually Owns a Patient’s Journey When Things Go Wrong?

      • When outcomes are poor, who is held accountable by leadership? Options: VP Care Mgmt / Clinical Ops, Chief Medical Officer, Value-based contracts team, Population health director, Finance/Revenue leadership, No clear owner
      • Describe the governance structure for cross-setting care (committees, cadences, veto rights). Who needs to sign off for changes?
      • Who are the likely internal champions and the likely blockers for a platform that changes workflows?
      • How do clinical teams prefer new workflows to be introduced—pilot teams first, dept-wide training, or top-down mandate? Options: Pilot then scale, Department mandates, Peer-to-peer embedding, Ad hoc
      • What decision criteria will your executive sponsors use to judge whether a new tool is worth the investment?

      If You Could Eliminate One Costly Outcome Today, Which Would It Be?

      • Which outcomes are highest priority for improvement in your contracts or internal goals? (select up to three) Options: 30-day readmissions, ED utilization, Potentially avoidable admissions, SNF reuse/long stays, Medication non-adherence, Behavioral health crises, Social needs-driven utilization
      • What are your current baseline rates or targets for those outcomes (attach numbers or describe trends)?
      • How do you currently attribute reductions in utilization to care management activities? (e.g., standard ROI model, proxy measures, not attributed) Options: Standard ROI model used, Proxy measures (touches, follow-ups), Ad hoc case reviews, Not attributed
      • What magnitude of reduction in ED visits/readmissions would make leadership sit up and approve continued funding? Options: ≥20%, 10–19%, 5–9%, <5%, Undetermined
      • What non-financial signals (staff burnout, patient experience, provider relationships) matter most when judging success?

      What Would Your Care Managers Do If They Had a Single Pane of Truth?

      • If every relevant data point (claims, ADT, SDOH, last provider note) were visible in one view, what would your care managers stop asking for?
      • Which workflows currently drain the most time from your care managers? (select all that apply) Options: Reconciling patient lists, Finding latest discharge info, Making outbound outreach, Referral coordination, Documenting care plans, Insurance/authorization tasks
      • How do care managers prefer to receive tasks/alerts—email, EHR inbox, mobile app push, daily task board, or integrated workflow? Options: EHR inbox, Standalone app inbox, Email, Mobile push, Daily task board/report
      • Describe one workflow change that would free up the most clinical time for proactive outreach.
      • What percent of your care managers' time is currently reactive (firefighting) versus proactive care coordination? Options: >75% reactive, 50–75% reactive, 25–49% reactive, <25% reactive

      Are Your Risk Scores Telling the Truth—or Just Noise?

      • How confident are you that your existing risk stratification identifies the right patients for intervention? Options: Very confident, Somewhat confident, Neutral, Not confident
      • Which inputs matter most to your risk models today (select all that apply)? Options: Recent ADT events, Claims history, Medication fills, Clinical labs, Social needs flags, Utilization history, Patient-reported outcomes
      • How do you validate or calibrate risk scores—retrospective review, prospective pilot, or none? Options: Retrospective review, Prospective pilot, Automated calibration, No formal validation
      • What false-positive or false-negative consequences are most painful (e.g., wasted CM time, missed high-risk patients)?
      • If we proposed a re-tuning cadence for risk models, how often would you want to review and approve changes? Options: Weekly, Monthly, Quarterly, Annually

      What Would Success Feel Like in 6 Months and in 18 Months?

      • If we delivered a successful pilot, what specific metrics would you expect to see at 6 months?
      • And at 18 months, what change would convince finance to expand investment?
      • Which acceptance criteria are non-negotiable for you to sign off on go-live? (select all that apply) Options: Data fidelity above threshold, Risk calibration validated, Workflow adoption by X% of users, Training completed for all roles, Security and HIPAA compliance
      • How will you measure sustained adoption after deployment—task completion rates, time-to-action, or user satisfaction? Options: Task completion / SLA, Time-to-action metrics, User adoption %, User satisfaction / NPS, Clinical outcome improvements
      • Which stakeholder will be the ultimate signatory that success has been achieved? Options: VP Care Mgmt, CMO, Head of Population Health, Finance lead, Cross-functional steering committee

      What Could Derail This Before You Even Start?

      • What are the top technical or operational blockers you’ve seen kill similar initiatives in the past?
      • How quickly can you provision a secure sample feed (ADT or claims) for a pilot? Options: <2 weeks, 2–6 weeks, 6–12 weeks, Longer than 12 weeks, Unable to provide
      • Which security or legal approvals tend to take the longest at your org (select all that apply)? Options: BAA / HIPAA review, Security penetration test, Data use agreements, Privacy office approval, Vendor contracting/finance
      • Describe any previous integrations that failed—what specifically was the root cause?
      • If integration, matching, or governance issues arise during pilot, what escalation path works best for you?

      Who Needs to Be in the Room for This to Stick?

      • List the people or roles who must be engaged for deployment and change management to succeed.
      • Which groups will you want included in weekly pilot standups (select all that apply)? Options: Care management leads, IT/integration, Data/analytics, Clinical champions, Finance, Compliance
      • Who is most likely to push back on workflow changes, and what do they fear losing?
      • Which clinical champions do you already have (names or roles), and how active are they? Options: Very active, Occasionally engaged, Potential but not committed, No champions identified
      • How would you like our team to partner on change management—train-the-trainer, co-led sessions, or turnkey support? Options: Train-the-trainer, Co-led sessions, Turnkey support, Ad hoc consulting

      Let’s Get Practical: Your Next Concrete Step

      • How ready is your org to start a pilot on a 3–6 month timeline? Options: Ready now, Ready in 1–2 months, 3–6 months, Longer / planning required
      • What pilot size would be meaningful but manageable (select one)? Options: Small team (10–50 patients), Program cohort (50–250 patients), Population slice (250–2,000 patients), Larger scale (>2,000)
      • Are you willing to provide a secure sample feed and a named pilot champion for a quick validation? Options: Yes, both, Yes, sample feed only, Yes, champion only, No
      • What would you like us to demonstrate first—data fidelity, risk tuning, or workflow prototype? Options: Data fidelity (sample feed), Risk tuning/calibration, Workflow prototype & role demo, All three at once
      • Is there anything else that would help you decide to proceed after this discovery conversation?
  6. Success

    Review outcomes versus agreed success signals, iterate care model and analytics, and maintain a shared channel for issues and enhancements.

    Success Reviews

    • Outcomes Review & Validation
    • Care Model Iteration Workshop
    • Analytics & Risk Model Calibration Session
    • Shared Channel, Issue Triage & Enhancement Governance
    • Quarterly Success Business Review (QBR)

    Issues & Enhancements

    • Provision the agreed shared channel and publish the triage form and SLAs.
    • Produce a short test runbook to operationalize the pilot in the platform.
    • Publish the pilot runbook (cohort definition, intervention details, success metrics) to the shared channel.
    • Platform team to schedule configuration changes and deliver a sandbox preview before pilot start.
    • Care management to nominate operational leads and training slots for pilot staff.
    • One‑Sentence Current Model State
    • Achieve a concrete calibration plan with measurable targets and a safe rollout approach.
    • Ensure analytics changes are tied to operational impact and validated before production rollout.
    • Define monitoring rules and SLA for model performance.
    • Analytics team to deliver a back‑test report and recommended threshold with expected impact estimates.
    • Set up a 14‑day shadow run and report template to evaluate proposed changes.
    • Create automated alerts for drift thresholds and assign on‑call owners.
    • Confirm Shared Channel & Access
    • Create a single source for ongoing communication and a clear triage process for issues and enhancements.
    • Assign operational and clinical owners with SLAs for common issue types.
    • Agree on a predictable change control and release calendar to minimize disruption.
    • Opening & One‑Sentence Current State
    • Document RACI and escalation contacts and circulate to all stakeholders.
    • Schedule standing weekly ops sync and monthly analytics review on calendars.
    • Executive One‑Line Current State & Outcomes Snapshot
    • Ensure executive alignment on whether agreed success signals justify acceptance, scale, or contract changes.
    • Secure approvals or resources needed to scale successful interventions.
    • Set prioritized roadmap and agreed metrics for the next quarter.
    • Produce an executive one‑page scorecard with ROI estimates and distribute to finance and operations.
    • If expansion approved, draft scope and timeline for scaling to additional cohorts or sites.
    • Schedule the next QBR and confirm required pre‑reads (data pack, pilot results).
    • Verify which agreed success signals are met, unmet, or partially met.
    • Surface the primary root causes for any gaps between observed outcomes and targets.
    • Validate interpretations through concrete patient scenarios (prove → validate).
    • Decide immediate remediation or acceptance and assign owners and timelines.
    • Deliver a outcomes evidence package (dashboard export, sample patient stories, data lineage) to attendees within 3 business days.
    • Owner assignment for each unmet signal with remediation plan and due date.
    • If accepted, prepare sign‑off document confirming success signals met and move to maintenance cadence.
    • Recap Findings from Outcomes Review
    • Convert outcome gaps into one prioritized pilot with clear hypothesis and measurable acceptance criteria.
    • Align sellers, clinical leads, and operational owners on configuration changes and responsibilities.
    • Re-state Agreed Success Signals
    • Metrics Review (Calibration & Performance)
    • Define Target Cohorts & Problem Statement
    • Financial & Operational Impact
    • Issue Triage Workflow & SLAs
    • Successes, Risks & Open Items
    • Change Control & Release Cadence
    • Failure Mode Analysis
    • Brainstorm Intervention Options
    • Data Presentation: Outcomes vs Targets
    • RACI for Escalations & Accountability
    • Consequence Analysis
    • Tuning Options & Tradeoffs
    • Design Pilot/Test Plan
    • Strategic Opportunities & Roadmap
    • Case Review: Proof from Real Patients
    • Decisions & Approvals
    • Platform Configuration Walkthrough
    • Recurring Maintenance Cadence
    • Recalibration Plan & Validation
    • Root Cause & Gap Diagnosis
    • Monitoring & Alerting Specs
    • Assign Owners & Timeline
    • Summarize Actions & Next Review
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