Care Coordination & Referrals
Expert articles and analysis related to care coordination & referrals.
AI Summary — Last 30 Days
Over the past 30 days, CMS, under the Trump administration, has advanced a significant structural pivot toward technology-enabled, outcomes-based care coordination through the voluntary ACCESS model, selecting 150 digital health partners and providers to test leaner, results-tied payments in chronic disease management—including diabetes, obesity, musculoskeletal pain, and depression. This model’s lower-than-expected payment rates and voluntary participation have prompted strategic recalibrations among ACOs, health systems, and tech firms, who are now vying to demonstrate scalable population health impact and cost savings—underscoring an intensifying emphasis on ROI-driven care enablement, partnership selection, and digital platform performance. Simultaneously, AI-driven care coordination solutions are rapidly scaling, with firms like Zynix AI deploying "Care Execution Agents" across nearly 1 million value-based care lives, illustrating a broader shift toward automation and actionable data integration as central enablers for VBC-era referral management and care transitions. Key sources: CMS announces 150 participants for ACCESS model, Zynix AI deploys Care Execution Agents at scale
Related Articles
Value Based Care Benefits of Strong Acute and Post-Acute Care Collaboration
Value Based Care Benefits of Strong Acute and Post-Acute Care Collaboration Healthcare IT Today
CMS launches model to improve care coordination for children and families
CMS launches model to improve care coordination for children and families American Medical Association
The post-acute blind spot: Why what happens after discharge matters more than ever
Post-acute care is healthcare’s biggest blind spot — and a major opportunity.
Care Coordination, Reimagined: How Tom Helps Primary Care Teams Deliver Better Care Before the Visit Even Begins
Care coordination has always been one of the most important, yet consistently fragile, aspects of primary care. Even in well-resourced health systems, essential steps like annual visits, preventive sc...
The Task Force Releases a Case Study Featuring MedStar Health’s Implementation of the GUIDE Model
WASHINGTON (March 31, 2025) – The Health Care Transformation Task Force (Task Force) – a group of leading health care payers, providers, purchasers, patient organizations, and value transformation par...
Reimagining Dementia Care: Lessons from Implementing the GUIDE Model
The Health Care Transformation Task Force and MedStar Health released a case study featuring MedStar’s implementation of the Guiding an Improved Dementia Experience (GUIDE) Model, a federal program de...
How Orlando Health is reshaping bariatric care
In a little more than a year, Orlando (Fla.) Health will open a new, centralized hub for obesity care, bringing together surgeons, obesity medicine specialists, nutritionists and behavioral health pro...
Sutter Health helps high-risk patients map out next steps
Sutter Health helps high-risk patients map out next steps American Hospital Association
CMS reveals new Medicaid model that supports coordination for children with complex needs
CMS reveals new Medicaid model that supports coordination for children with complex needs Fierce Healthcare
Opinion: We’re launching a new CMS pilot program to help children with complex conditions
CMS wants “to turn this shoddy patchwork of care into a seamless tapestry,” write CMS Administrator Mehmet Oz and Center for Medicare and Medicaid Innovation Director Abe Sutton.