6 Executive Strategies for Optimizing Care Coordination and Delivery 

At a recent roundtable, the HealthEdge® Chief Medical Officer led executives from three leading health plans in a discussion centered around optimizing care delivery and efficacy while improving cost control and payer performance.

Panelists included:

• Chief Medical Officer at a member-owned health insurance company based in Illinois
• President at a Washington D.C.-based health plan focused on children and young adults receiving Supplemental Security Income (SSI)
• Department Vice President and Medical Director of Population Health at a not-for-profit health plan based in Kansas

1. Putting Members at the Center of Care Delivery

Department Vice President and Medical Director of Population Health: We see a unique opportunity to reposition ourselves and rearticulate the value of enabling and coordinating care to serve members well. First, we concentrate on clinical improvements. Second, we prioritize the member experience.

The healthcare ecosystem is inherently complex, and our role is to guide members through their journeys. We dedicate significant resources to high-cost claimants, as 1-2% of members can account for 30-50% of a plan’s total spend. We lead high-cost claimant rounds to review claims experiences, where a simple question like “How is the member doing?” shifts the focus from data points back to the individual.

This proactive outreach often provides the first indication of an upcoming issue that claims data would not show for another six months. It allows for more effective care coordination and fosters an empathy-driven mindset, ensuring we never lose sight of the people we serve.

In terms of outcomes, our care management programs achieve satisfaction scores in the mid-to-high 90s. As an organization, we prioritize the ease of doing business with our health plan, and we are outperforming market benchmarks. Most importantly, we translate these insights into actionable opportunities for our provider partners through value-based agreements and other relevant structures.

2. Driving Value-Based Reimbursement

Health Plan President: The journey to value-based reimbursement is unique in the pediatric space. Pediatric providers typically don’t take Medicare, so they have been mostly insulated from payment innovations. Our first obstacle was incentivizing them to even discuss alternative payment models.

We learned that value-based reimbursement starts with an engaged workforce within our health plan. Our first step was to define what we wanted to accomplish as an organization and how we would partner with providers to achieve it.

We used three strategies to achieve our goal:

1. Breaking Down Internal Data Silos: We used the HealthEdge GuidingCare® platform to bring Utilization Management, Care Management, and Appeals and Grievances into one integrated system. This provides our care managers with a 360-degree view of their members, including complaints, legal settlements, and care gaps. We then expanded access to our marketing, outreach, and customer service teams.
2. Embedding Care Managers: As our care management staff gained a complete view of the member, we embedded them in provider offices. This creates an interdependent relationship where providers and care managers can align their goals.
3. Leveraging Shared Data: We established a shared population health platform with our largest national provider. We don’t need to question each other’s data because we all see the same information. This allows us to focus on our mutual goals, which are set jointly through a shared governance model and reviewed monthly to ensure they remain accurate.

3. Strengthening Payer and Provider Collaboration

Chief Medical Officer: We also leverage GuidingCare as a unified platform for medical management and population health. One key function is allowing providers with a treating relationship to view a member’s care plan. This facilitates co-management and presents a coordinated care approach to the member.

Our collaborative efforts focus on two areas: Data transparency and value-based contracting.

• Data Transparency is essential for building strong and effective collaboration. We use Admission, Discharge, Transfer (ADT) feeds, health data exchanges, and other platforms to ensure transparent data flow between the payer and provider.
• Value-based contracting is a tool to align cost and quality metrics between providers and payers. We incentivize providers to support work that ultimately serves the person, whether we call them a member or a patient. Through Joint Operating Committees, we review leading indicators monthly to identify and address unfavorable trends early on.

We’ve learned two crucial lessons:

1. We must agree on what success looks like through a conversation with the provider, ensuring measures are relevant, reliable, and impactable.
2. We must structure contracts based on provider type, setting, population served, and their comfort level with accepting risk. Not everyone is ready for a full-risk contract. We guide them along the alternative payment model spectrum, from foundational steps to shared savings and losses, and eventually to full-risk contracts.

By applying these lessons and interventions, we’ve seen increased interest in higher-risk models, with providers more willing to take on these contracts because they feel equipped with the right tools and resources to succeed.

4. Utilizing Digital Tools for Care Management

Department Vice President and Medical Director of Population Health: Our historical data showed that telephonic care management engagement rates were dwindling, so we invested in HealthEdge Wellframe™ and GuidingCare as our digital care management front door. It turns out that many members would rather text than talk.

In 2025, 32% of our meaningfully engaged members have engaged digitally. That represents a significant missed opportunity had we not adopted a digital tool. When comparing engagement in care management programs this year to the same period last year, we are up 23%. This shows that if we are truly member-centric, we must meet members where they are and offer multiple engagement preferences.

To achieve this, we are reimagining member engagement by integrating digital tools with our community health worker program. This approach takes care directly to the community, enabling us to drive better population health outcomes.

5. Personalizing Care Plans for High-Risk Members

Health Plan President: Delivering personalized care hinges on strong care management relationships, which can be challenging with healthcare workforce turnover between 20-25%. To address this, we created care management pods, assigning a team (with nurses, social workers, and community support workers) to each enrollee’s medical home, ensuring continuity despite staff changes.

This relationship also impacts technology adoption. When we first implemented Wellframe, member adoption was low. This stemmed from care managers not embracing the tool due to productivity concerns. For complex populations, a primary care physician isn’t always the medical home—much of their care comes from specialty practices. Our model focuses on collaboration between the specialty medical home and the primary care medical home, with the care manager acting as the “glue” that directs traffic and brings everyone together.

True integrated care means ensuring smooth care transitions for members across different settings.

6. Closing Gaps in Care with Real-Time Data & Analytics

Department Vice President and Medical Director of Population Health: We have a lot of data, but the key is filtering through it to find actionable opportunities. One project we worked on was a multi-modality gap-in-care program using Healthcare Effectiveness Data and Information Set (HEDIS) methodology. We would trigger communications to members when they had an open care gap.

One leader at our organization went a step further and weighed the different gaps, so if a member had multiple gaps, we knew which one to prioritize in our communication. We pushed these notifications out through multiple channels: our mobile app, our care management app, and our customer service reps, who had scripts ready.

We also discovered that while members don’t open a lot of their mail, they almost always open their Explanation of Benefits (EOB). We started putting care gap notifications directly on the EOB, along with a QR code for our Wellframe app, and it’s been amazing to see how many people have used it to take a more active role in their care.

Over the past year, this pilot closed thousands of care gaps, with a success rate of over 50% for directly engaged members. Most importantly, these insights are helping drive population health outcomes collaboratively with providers.

Innovative Solutions for the Future of Care Delivery

Addressing challenges like care coordination, cost control, and provider collaboration requires innovative solutions that prioritize transparency and seamless workflows.

By focusing on enhanced member engagement and proactive care delivery, payers can help create a system that delivers better outcomes for members, reduces costs, and improves satisfaction.

Want to learn more about how health plans are leveraging digital solutions to improve data accuracy, transparency, and efficiency? Access insights from a payer executive roundtable in our recent article, “Unlocking the Future of Healthcare Technology: Interoperability, Transparency, and AI.”