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You have to think beyond a patient's disease process and think about how they engage with the healthcare system, explained Jason Mitchell, MD, chief medical and clinical transformation officer, Presbyterian Healthcare Services.

Looking at readmissions for congestive heart failure, we realized that the majority of our patients were being readmitted because of care coordination and social determinants of health, explained Susan Mani, MD, vice president of Clinical Transformation and Ambulatory Quality at LifeBridge Health.

Organizations are trying to think about how they can involve team-based care by incorporating individuals who have a certain skill set that can relieve the practicing clinician, physician, nurse practitioner, or physician assistant from some of the burden, explained Dennis P. Scanlon, PhD, professor, Health Policy and Administration, and director, Center for Health Care and Policy Research, Pennsylvania State University.

The endgame for both the health system and the payer is always the patient, so we try to focus on treating patients in the most cost-effective manner with the most clinically appropriate evidence-based approach, explained Ashley Pappas, PharmD, MHA, assistant director of pharmacy, University of North Carolina Hospitals.

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