inVio Health Network catalyzes performance gains using a rich data set to risk-stratify patients

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High-performing clinically integrated networks stand out for their ability to operationalize clinical transformation using a data-supported approach to patient care. Clinical data alone creates only a partial picture. Manual chart reviews and interventions triggered only by ADT events often leave care managers consumed with care transitions — and rising-risk patients with complex or chronic conditions can fall through the cracks. 

70% Fewer readmissions

58% Fewer ED visits

75% Fewer admissions

66% Lower total cost of care

The limits of clinical data alone

inVio Health Network, affiliated with Prisma Health, manages over 600K lives across South Carolina and East Tennessee. The network's prior approach relied heavily on clinical data from Epic and other EHRs, but the limitations were clear:

• Manual chart review consumed staff and care manager time with limited upside
• Variability in data input made quality measure calculation challenging
• Attribution relied solely on provider referrals from patient panels, mixing attributed and non-attributed lives
• ED and hospital utilization went uncaptured for patients who bypassed primary care
• Providers questioned the fairness of calendar-year-only attribution logic

A richer data model changes the equation

inVio Health Network partnered with Innovaccer to enrich its patient records with ACG Risk Score, high-cost claimant flags, preventive care adherence, and medication adherence data. Innovaccer's AI normalizes and curates tens of millions of clinical data points alongside claims data, analyzed and grouped using  the Johns Hopkins ACG system.

The result: a proprietary Composite Risk Score (CRS) for every patient, built across four domains, clinical needs, financial needs, SDOH needs, and adherence needs, that determines who receives which services, and when.

Integrated care at scale: the Care Team Pod model

The CRS powers patient selection for inVio Health Network's Integrated Care Management program. More than 33,500 complex and chronic disease patients are assigned to interdisciplinary Care Team Pods, each composed of an RN care manager, social worker, health coach, behavioral health care manager, and clinical pharmacist. The pods coordinate care delivery, social resources, palliative support, and condition-specific education.

Over 14K patients are enrolled in remote patient monitoring and chronic care management programs covering diabetes, COPD, asthma, hypertension, and high cholesterol. For patients who do reach the ED or hospital, multiple care transition models ensure safe discharge and ongoing community management, reducing the likelihood of a second emergent episode.