Value-based care is no longer a future concept—it’s actively reshaping how providers deliver care, especially for complex chronic conditions like kidney disease. In an episode of the Outcomes Rocket Podcast, host Saul Marquez sat down with leaders from PRINE Health and ThoroughCare to explore how care coordination and technology are driving better outcomes.
Featuring insights from Colette Boroch, Director of Clinical Services at PRINE Health, Jonathan Goldstein, CFO at PRINE Health, and Kathryn Anderton, VP of Clinical Operations at ThoroughCare, this conversation highlights what it takes to succeed in value-based care today—and what lies ahead.
What Is Value-Based Care—and Why It Matters
At its core, value-based care aligns financial incentives with patient outcomes. Instead of rewarding volume, providers are incentivized to improve quality, reduce avoidable costs, and deliver coordinated, patient-centered care.
For chronic conditions like kidney disease, this shift is critical. Without proactive management, patients often face:
- Frequent hospitalizations
- High-cost treatments like dialysis
- Fragmented care across multiple providers
Value-based care aims to change that by emphasizing early intervention, continuous engagement, and coordinated care delivery.
The Role of Preventative Kidney Care
At PRINE Health, preventative kidney care is a cornerstone of their model. According to Colette Boroch, early identification and patient education are essential to improving outcomes.
Rather than reacting to late-stage disease, their teams:
- Screen and identify patients earlier in the disease progression
- Provide ongoing education about treatment options
- Help patients navigate complex care decisions, including dialysis and transplant options
This proactive approach helps prevent patients from “crashing” into emergency situations—reducing both patient suffering and overall healthcare costs.
Why Care Coordination Is the Backbone of Success
Care coordination is one of the most critical—and challenging—components of value-based care.
As Kathryn Anderton explains, fragmented systems and manual workflows often stand in the way. Providers frequently deal with:
- Disconnected EHR systems
- Inconsistent data across care teams
- Time-consuming documentation requirements
- Staff burnout, especially among care managers
That’s where platforms like ThoroughCare come in—helping reduce administrative friction so clinicians can focus on what matters most: the patient.
Key Benefits of Strong Care Coordination:
- Improved patient engagement and trust
- Better medication adherence and follow-up care
- Reduced hospital readmissions
- More consistent tracking of outcomes over time
How Technology and AI Are Transforming Care Management
Technology is playing an increasingly vital role in scaling care coordination efforts.
From workflow automation to AI-powered insights, modern platforms are enabling:
- Real-time patient tracking and reporting
- Automated documentation and assessments
- Identification of high-risk patients earlier
- Streamlined communication across care teams
Importantly, AI is not replacing care managers—it’s augmenting them.
As discussed in the episode, tools like ambient listening and AI transcription allow clinicians to focus more on patient conversations and less on documentation. The result: better experiences for both patients and providers.
A Real-World Success Story: The Power of Relationships
One of the most compelling moments from the conversation was a patient success story shared by Colette Boroch.
After working with a challenging patient for over a year, her team was able to:
- Build trust through consistent engagement
- Identify barriers to care (transportation, scheduling, emotional resistance)
- Coordinate critical appointments for dialysis preparation
Without that relationship and persistence, the patient likely would have ended up hospitalized. Instead, she successfully began treatment on time—avoiding a crisis.
The takeaway: Care management is not transactional—it’s relational. And those relationships take time.
Measuring What Matters: Outcomes in Value-Based Care
Success in value-based care isn’t just about cost savings—it’s about meaningful patient outcomes.
Some of the most important metrics include:
- Reduced hospital readmissions
- Improved chronic condition management (e.g., blood pressure, A1C levels)
- Higher patient engagement and satisfaction
- Lower total cost of care
One striking insight shared in the episode: patients who don’t follow up with their primary care provider after discharge face significantly higher readmission risks. This underscores the importance of Transitional Care Management and timely follow-ups.
Overcoming Challenges in Value-Based Care
Despite its promise, value-based care comes with real challenges:
1. Fragmented Data Systems
Multiple EHRs and disconnected workflows make coordination difficult.
2. Provider Buy-In
Success depends on physicians embracing care management as an extension of care—not a replacement.
3. Operational Complexity
Launching and scaling programs requires infrastructure, reporting, and staffing.
4. Payer Dynamics
Some payers are pulling back on reimbursements for care management services, creating uncertainty.
Expert Advice: How to Succeed in Value-Based Care
The panel shared practical guidance for organizations looking to enter or expand value-based care:
Start Small and Scale
Focus on a subset of patients or metrics, learn, and expand.
Invest in Infrastructure Early
Build workflows, reporting capabilities, and care teams before scaling.
Track and Report Outcomes
Be prepared to demonstrate impact from day one.
Partner Strategically
Don’t reinvent the wheel—leverage platforms and partners with proven solutions.
Focus on High-Risk Patients
Prioritize those who will benefit most from coordinated care.
The Future of Value-Based Care: What’s Next?
Looking ahead, the future of value-based care will be shaped by:
- Greater adoption of AI and predictive analytics
- Improved interoperability between systems
- Expansion beyond Medicare Advantage into broader populations
- Increased emphasis on proving outcomes—not just delivering services
As healthcare continues to evolve, one thing is clear: technology-enabled, relationship-driven care coordination will be at the center of it all.
Final Thoughts
Value-based care is more than a payment model—it’s a fundamental shift in how care is delivered.
Organizations like Prine Health and ThoroughCare are demonstrating that with the right combination of:
- Clinical expertise
- Technology infrastructure
- Patient engagement
- And strong partnerships
…it’s possible to deliver better outcomes while reducing costs.
For providers navigating this transition, the message is simple: start now, stay focused on outcomes, and build the systems needed to scale.
