Adding a Measure of Self-Management Capability to Risk Assessment Can Improve Prediction of High Costs Less “activated” patients are more likely to benefit from care coordination. Peer-Reviewed Article March 2016
Utilization of Hot Spotting to Identify Community Needs and Coordinate Care for Patients in Memphis, TN The approach identifies patients through chart review and data analytics coupled with the intelligence of community health workers. Peer-Reviewed Article February 2014