Explaining the impacts achieved by focusing on a population considered at high risk for readmission and pairing those individuals with a dedicated care coordinator, Ms. Wickey and Dr. Hansen cover the following areas:

• Inventory and assessment of the roles of patient navigators, case managers, patient-centered home care managers and ACO care managers;
• The health system's 11-point punch list for increasing efficiencies across the care continuum;
• Criteria for determining the high-risk target Medicare population;
• Essential elements of multidisciplinary, data-driven patient-centered care management;
• Establishment of a centralized, patient-centric care management hub;
• The role of registries in tracking chronic illness in high-risk patients;
• Key results from the organization's robust care management redesign;
• And much more.