Off the Shelf TA

Refining Collaborative Care and Referral Pathways

The importance of taking steps to outreach to, engage, manage, or effectively transition after discharge those patients with chronic or complex conditions has never been clearer. This is particularly true given the current up-side and down-side risks associated with MCO contracting. JSI has honed a collaborative approach that assists ACOs to better understand and address the challenges they face with respect to their collaborative care and referral pathways in high-value areas such as outreach, screening, engagement, chronic disease management, behavioral health triage, and care transitions. Taking care to build on current assets and strengths, JSI works both independently and collaboratively with an ACO workgroup to: a.) Assess the relevant consumer and operational landscape, b) Identify and present relevant literature and best practice approaches, 3) Come to agreement on refinements to current operations, guidelines, collaborative care and referral pathways, and 4) Develop an action-oriented implementation plan. The process is informed by quantitative data and an understanding of evidence-based practices and driven by a series of individual and group meetings with ACO staff across care delivery settings. The culmination of this work is an agreed upon series of staged recommendations aimed at:

  • Maximizing existing resources;
  • Promoting team-based care (including community partnerships);
  • Revising and fostering the use of clinical guidelines;
  • Reducing wait times, no-show rates and system leakage;
  • Enhancing operations; and
  • Facilitating measurement and performance improvement.

The process must be tailored to ACO needs and the clinical and programmatic areas where there is thought to be the most value. At the outset of the meeting, JSI staff will work with the client to identify the specific scope and custom the process to meet client needs.


John Snow, Inc.


$25,000 - $75,000


Ongoing Availability


2 to 4 months


Either single or multiple participants (one ACO or CP per TA project OR multiple ACOs or CPs per TA Project)


Care Coordination / Integration

Community-Based Care and Social Determinants of Health

Consumer Engagement