One theme emerged loud and clear at the NAACOS Spring 2025 Conference: transformation isn’t just about systems. It’s about people, collaboration, and actionable workflows. 

Healthcare organizations nationwide are navigating the complexities of value-based care (VBC). VBC success is measured in procedures performed and outcomes achieved. It requires coordination between technology, teams, and providers. 

Many organizations are struggling to close the gaps.

Patients shouldn’t fall through the cracks 

A shared concern emerged throughout the conference: too many patients are falling through the cracks. Patients miss out on critical preventive services and coordinated interventions for several reasons: 

• Fragmented care 

• Lack of follow-up 

• Systemic blind spots 

Collaboration — fueled by technology, workflows with proper incentives, and strong provider engagement — was the consensus solution. Organizations are working to reward physicians for participation and effective implementation. This includes building workflows that support comprehensive care coordination and make physicians’ jobs easier, not harder. 

Annual wellness visits are a primary focus. They often go overlooked due to scheduling challenges or lack of provider incentives.  

One organization shared how reworking scheduling systems and incentivizing providers led to a 42% increase in completion rates for annual wellness visits. This significantly improved care-gap identification. 

Managing complexity with team-based approaches 

Shifting to value-based care adds complexity, from contract management and revenue analysis to meeting quality targets. To navigate this, organizations are: 

• Setting annual goals 

• Analyzing contract overlaps 

• Aligning staff efforts around key performance areas like HCC coding, transitions of care, screenings, and annual wellness visits 

Nurses drive many clinic workflows, fostering day-to-day patient engagement. Paired with quality specialists, they form the backbone of compliance and performance monitoring. Population health analysts and finance teams help ensure all efforts align with organizational goals. 

Why HCC coding and screenings matter 

HCC (Hierarchical Condition Category) coding isn’t just a billing issue — it’s a strategic lever. Accurate coding ensures proper documentation for patients’ conditions. This influences contract revenue and Medicare reimbursements. Regular provider education and quarterly coding audits have led to more accurate MLR (Medical Loss Ratio) performance and improved contract payouts. 

Targeted screenings, especially those tied to chronic conditions like diabetes, are another opportunity to close gaps and improve long-term outcomes. Some organizations have adopted standing orders, allowing the entire care team to initiate screenings. Others have invested in innovative tools like a mobile diabetic eye exam “momovan” to bring care directly to underserved areas. Performance bonuses and clinic-based incentive funds have also engaged staff. 

Reducing readmissions through better transitions of care 

Readmissions remain a stubborn challenge in value-based models. One organization tackled this by building a daily census tool to track inpatient admissions and trigger workflows as patients are discharged. It led to a 24% reduction in readmission rates for attributed lives. 

Deliberate planning, cross-functional coordination, and workflows that focus on patient follow-up and recovery are keys to achieving this kind of impact. 

Care management: Guiding patients beyond the hospital 

A patient’s journey doesn’t end when they leave the hospital or emergency department. Many need navigation support, especially when dealing with chronic conditions, mental-health issues, or social determinants of health (SDOH). Emergency-department care navigation and local resource connection are increasingly recognized as essential components of effective care management. 

By identifying barriers to care like transportation, housing, or food insecurity, organizations can intervene earlier and more meaningfully. This kind of wraparound care improves health outcomes, patient trust, and engagement. 

Key takeaways 

Several lessons emerged from the NAACOS Spring 2025 Conference sessions: 

• Physician buy-in is essential. Engagement starts with listening to providers, understanding their workflow challenges, and offering the right mix of incentives and support. 

• Clear, empowered workflows drive success. From nurses to analysts, every role plays a part in making value-based care work. 

• Incentivizing transformation works. Whether it’s through shared savings, performance bonuses, or clinic-based funds, recognizing the effort behind care improvements is key to sustaining change. 

As healthcare continues to shift toward value, organizations that invest in collaboration, clarity, and care coordination will be best positioned to succeed. With the right people and processes in place, meaningful change is possible, and, in some places, already underway.  

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