A study written by five FHCHC staff members, and appearing online and ahead of print in Population Health Management, showcases the positive impact that care coordination can have on helping to identify preventable hospital stays. Following a group of patients with high-risk, chronic diseases such as diabetes, COPD, and congestive heart failure, FHCHC staff (comprised of Susan Roman, Director of Care Coordination; Dr. Lacey Whitmire, Population Health Medical Director; Lori Reynolds, Population Health Nurse Administrator; Anthony Brockman, Data Director, and Dr. Ben Oldfield, Chief Medical Officer) identified predictors of return hospital stays so that these indicators can be screened for in advance to head off unnecessary hospitalization. The study focused on workflows for care coordination and other service referrals, so that we can prioritize patients and their families who may need them the most. The full manuscript can be read here.