Care Coordination & Referrals
Expert articles and analysis related to care coordination & referrals.
AI Summary — Last 30 Days
CMS is pushing care coordination deeper into specialty and longitudinal chronic care: the TEAM episode model is driving tighter hospital-to-home health handoffs and greater outpatient substitution, while the ACCESS Model expansion adds chronic care tracks for heart failure, COPD, substance use disorders, and tobacco use beginning in 2027, signaling a broader move toward tech-enabled, condition-specific VBC infrastructure. For ACOs, health systems, and payers, the strategic pressure is shifting from generic referral management to closed-loop specialty, post-acute, pharmacy, and home-based pathways that can document longitudinal outcomes and total-cost impact across Medicare and Medicaid populations. See: TEAM and home health coordination and ACCESS Model expansion.
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