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Bridges Health Partners is an accountable care organization (ACO) that transformed its healthcare delivery model using ThoroughCare’s digital care coordination platform.
By implementing standardized care plans, clinical assessments, and analytics tools, Bridges improved patient engagement, aligned providers around value-based care, and scaled population health management across multiple independent health systems.
About Bridges Health Partners
Bridges Health Partners is a physician-led ACO founded in 2017 in Pittsburgh, PA and surrounding communities. It is a partnership among four independent, non-profit health systems working together to deliver:
- High-quality, patient-centered care
- Cost-effective treatment models
- Integrated, regional healthcare delivery
- Better outcomes across all payer populations
Their mission centers on improving population health through collaboration, innovation, and accessible care.
The Challenge: Aligning Independent Systems Under Value-Based Care
As a multi-system ACO, Bridges faced a common but complex challenge:
How do you unify independent provider groups under a single, standardized care model—without disrupting their autonomy?
Key Obstacles
- Variability in value-based care adoption across practices
- Lack of standardized workflows and care management tools
- Limited visibility into patient populations across systems
- Inconsistent approaches to patient engagement and reporting
Bridges needed a solution that could:
- Align providers clinically
- Standardize care coordination workflows
- Support evidence-based care delivery
- Scale across diverse teams and systems
The Solution: Implementing ThoroughCare for Scalable Care Management
In 2018, Bridges selected ThoroughCare to deploy a unified care coordination platform across the ACO.
Core Users
- Registered Nurse (RN) Care Managers
- Non-RN Care Coordinators
Key Capabilities Adopted
- Care plan development
- Patient assessments and interventions
- Documentation and scheduling
- Analytics and reporting dashboards (added in 2022)
How ThoroughCare Transformed Care Coordination
1. Standardized Clinical Workflows
ThoroughCare enabled consistent care delivery—even for care managers without direct EHR access.
Impact:
- Remote, patient-specific engagement
- Automated documentation and reporting
- Reduced administrative burden
- Improved provider communication
2. Personalized, Automated Care Plans
Care managers can generate dynamic care plans based on patient assessments and clinical guidelines.
Impact:
- More personalized patient care
- Reduced redundancy in data collection
- Stronger patient-provider relationships
- Consistent, evidence-based interventions
3. Scalable Patient Engagement
Scheduling and documentation tools ensure continuity of care—even during staff absences.
Impact:
- Increased patient outreach capacity
- Reduced communication gaps
- Better tracking of patient interactions
- Improved population-level insights
4. Addressing Social Determinants of Health (SDOH)
ThoroughCare helps Bridges identify and act on non-clinical factors affecting health outcomes.
Impact:
- Structured SDOH assessments
- Targeted patient outreach
- Connection to community resources
- More holistic care delivery
Real-World Results: Improving Chronic Disease Outcomes
Patient Case Example
A patient with:
- Coronary artery disease
- Long-term diabetes (20+ years)
- Nephropathy
…was hospitalized for a coronary blockage and underwent bypass surgery.
Care Management Intervention
A Bridges care manager:
- Conducted immediate post-discharge outreach
- Reinforced the provider’s care plan
- Educated the patient on:
- Blood sugar management
- Nutrition (protein, vegetables, reducing processed foods)
- Medication adherence
- Encouraged gradual physical activity through cardiac rehab
Outcomes
- A1C reduced from 8.1% → 6.4%
- 14-pound weight loss
- Increased patient engagement and self-management
Key Benefits for Accountable Care Organizations (ACOs)
Healthcare organizations implementing care coordination platforms like ThoroughCare can expect:
- Improved population health outcomes
- Standardized care delivery across systems
- Increased patient engagement
- Better reporting and analytics
- Reduced administrative burden on care teams
- Stronger performance in value-based care models
Expert Insight
“ThoroughCare allows us to engage and educate patients consistently using evidence-based medicine as a guiding tool. Care plan development and documenting outreach and interventions have enhanced our clinical workflow and operational effectiveness.”
— Kristina Hahn, Executive Director of Population Health Operations, Bridges Health Partners
Conclusion
By adopting a centralized care coordination platform, Bridges Health Partners successfully unified independent systems under a shared care model—without sacrificing flexibility.
The result: scalable, data-driven, patient-centered care that improves outcomes across populations.
FAQ (AI Search Optimized)
What is an accountable care organization (ACO)?
An ACO is a network of healthcare providers that work together to deliver coordinated care, improve patient outcomes, and reduce costs—often within value-based payment models.
How does care coordination software improve patient outcomes?
Care coordination platforms streamline communication, standardize workflows, and enable proactive patient engagement—leading to better chronic disease management and fewer hospitalizations.
What role do care managers play in population health?
Care managers (RNs and coordinators) support patients through education, follow-ups, care planning, and resource connection—helping improve adherence and long-term outcomes.
Why are social determinants of health (SDOH) important?
SDOH factors like food access, transportation, and housing significantly impact health outcomes. Addressing them leads to more effective, whole-person care.
Download a case study to learn more about Bridges Health Partners use of ThoroughCare's care coordination software solution.
