The situation
Every hospital discharge or ED visit for our care management population opens a narrow, high-value window — a chance to reach the patient during the highest-risk period after they leave the hospital, confirm they understand their care plan, and close gaps tied to quality measures. As referral volume grew 20–30% month over month, care managers worked through several hundred of these events monthly with no way to know which ones mattered most until they'd already gone through the list.
Triage was manual — a mix of analytics dashboards and a shared spreadsheet — and treated most events the same regardless of readmission risk, contract value-based standing, or prior outreach attempts. That reactive approach consumed enough capacity that there was little room left for the proactive, longitudinal care management that actually helps prevent readmissions.
Building a prioritization score, not just a queue
I led the design of a scoring model that turned what care managers were already weighing informally and inconsistently into a single, transparent priority order on each care manager's worklist:
-
Value-based standing
Patients in a formal value-based contract, or referred by an organization we're building toward one, were weighted above fee-for-service patients — reflecting where outreach has the greatest clinical and financial upside.
-
Clinical risk
Each event's individual readmission risk weighed heaviest, with eligibility for behavioral-health and chronic-condition quality measures layered in as a secondary factor.
-
Urgency
Events were weighted higher the more recent the discharge, since outreach effectiveness and readmission-prevention impact both drop off with time.
-
Effort already spent
The score also factored in outreach already logged — assessment status and attempt count — so care managers weren't re-working patients already reached, or skipping ones who hadn't.
What changed
The new worklist launched alongside a staffing shift: LPNs took over day-to-day outreach from the prioritized list, freeing RNs for the proactive care management work that's hard to do while purely reactive.
Beyond the topline numbers, the shift changed the job for both roles. LPNs now work from a single, defensible list — no more piecing one together from a report and a spreadsheet — while RNs got real capacity back for outreach that's hard to justify when you're always reacting to yesterday's volume. The worklist also gave the product team its first persistent view into outreach performance, which is already shaping the model's next iteration.
Figures reflect internal program metrics current as of Q1/Q2 2026, generalized for public sharing; specific contract, payer, and internal system names have been omitted or simplified.