Care Coordination & Referrals

Care coordination is increasingly being pulled into condition-specific and episode-based VBC models: the TEAM demo is positioning home health as a post-acute partner to prove avoidable utilization reduction, while BCBSM/TRIARQ’s MSK model emphasizes earlier specialist engagement to steer patients away from unnecessary procedures and into appropriate pathways (MSK model case study). At the same time, measurement and infrastructure expectations are tightening, with NCQA moving HEDIS Transitions of Care toward ECDS reporting—raising the bar for interoperable discharge, medication, and follow-up data exchange across ACOs, MA plans, hospitals, and post-acute networks (NCQA TRC ECDS update). The net signal for VBC leaders is that referral management is shifting from informal network leakage control to digitally measured, condition-specific coordination across specialists, home health, and community providers.