The care management team had developed its Transition of Care process around one clear commitment:

“Never miss a patient after discharge.”

At the center of that process was a shared Excel tracker that had been built and maintained over several years. Every patient discharge was manually reviewed and entered by care coordinators.

The process was highly manual, but it reflected years of operational experience. The team understood that ADT feeds could occasionally be delayed or incomplete, so they had created a workflow they could trust.

Many solutions would have tried to replace the spreadsheet.

We didn’t.

Instead, we treated it as an important part of the organization’s operational knowledge. The tracker was incorporated into the data model and used alongside ADT data to calculate Transition of Care metrics and identify patients requiring follow-up.

The team was able to preserve the workflow it trusted, while leadership gained reliable visibility into care gaps, follow-up performance, and opportunities to reduce avoidable readmissions.

Sometimes the best workflow isn’t the newest technology. It’s the one people trust enough to use every day.

What Changed

Before

Teams maintained a trusted Excel tracker that operated separately from enterprise reporting.

After

The existing workflow became part of the reporting system, giving leaders a reliable view of follow-up activity, care gaps, and patient needs.

The organization had developed a sophisticated incentive program to align provider performance with value-based care. As the program evolved, however, its multiple measures, weights, scoring tiers, and performance directions became difficult to translate into a clear view for individual providers.

Providers remained focused on delivering excellent care, but they lacked a timely understanding of which specific improvements would have the greatest impact on their overall performance and incentives.

Each bonus cycle also required significant time from leadership to answer questions and explain the underlying calculations. The program was designed to motivate improvement, but its complexity made it difficult for providers to connect individual measures with the outcomes they were working toward.

Rather than redesigning the incentive program, we made it visible.

We translated the underlying logic into an interactive, automated report that showed each provider’s current performance, distance from the next scoring tier, and how improvements in individual measures could influence the overall incentive.

The bonus formula didn’t change.

People’s understanding of it did.

Providers could see which opportunities mattered most, focus their efforts where they could have the greatest impact, and move toward the organization’s goals with greater clarity and confidence.

An incentive becomes meaningful when people can see how today’s actions influence tomorrow’s outcomes.

What Changed

Before

Providers received a bonus without fully understanding how it was calculated or which measures offered the greatest opportunity for improvement.

After

Providers could see how current performance, improvement opportunities, and scoring thresholds translated into future incentives.