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next chapter.

Understand how care quality, patient outcomes, teamwork, and payment connect.

Coordinate assessment, care planning, referrals, follow-up, and communication across a person’s care team.

Build workflows that help people manage ongoing conditions between visits.

Support people as they move from hospital care to home and community services.

Plan the people, processes, and communication that support remote monitoring.

Connect behavioral health needs with assessment, referral, care coordination, and follow-up.

Help people access services, overcome barriers, and stay connected to care.

Coordinate nutrition resources and support people in carrying out a provider-directed plan.

Coordinate vaccination outreach, authorized service delivery, records, and reporting.

Support screening completion, result tracking, and coordination of necessary follow-up.

Coordinate assigned diabetes-related tests, screenings, documentation, and follow-up.

Support accurate measurement workflows, documented results, and appropriate follow-up.

Support approved screening workflows and timely connection to follow-up care.

Engage participants, remove access barriers, coordinate appointments, and track completion.

Prepare complete evidence and understand the payment and reporting process for assigned work.

Help people identify medication-access barriers and connect with their clinical or pharmacy team.