Prisma Health's clinically integrated network had already built the care model it believed in.Across South Carolina and East Tennessee, care managers were embedded inside primary care practices. Transitions of care nurses worked inside hospitals. ED navigators focused on Medicaid patients with repeated emergency department visits. Interdisciplinary "Care Team Pods" combined social workers, pharmacists, behavioral health managers and nurses into coordinated teams.The operational framework was in place. The problem was visibility."Our ambition exceeded what our data could support," said Dr. Bill Gerard, CEO of inVio Health Network and executive vice president of value-based care at Prisma Health.A fragmented viewPrisma Health is a 19-hospital, nonprofit health system based in South Carolina. Its clinically integrated network, inVio Health Network, includes more than 7,000 providers, more than 800 practice locations, 22 hospitals and dozens of post-acute partners. The organization manages more than 600,000 lives across public and private contracts.But even with that scale, Gerard said the health system struggled to create a complete, real-time picture of patients moving through multiple care settings.Electronic health records could document what happened inside a single care environment, but they were not designed to create a continuously updated longitudinal view that combined claims, medication history, utilization patterns and risk scoring across an entire network."If a patient did not come through primary care, we often could not see their ED visits, hospital admissions, pharmacy fills or utilization patterns elsewhere in the system," Gerard said.Care managers spent hours manually reviewing charts and piecing together patient histories from disconnected systems. Variations in data entry across sites complicated quality measurement and made provider engagement difficult."Our trigger model was almost entirely event-based, driven by ADT messages and provider referrals, which meant our care managers were perpetually downstream of the events we were supposed to prevent," Gerard said.Building a longitudinal patient recordPrisma Health turned to the population health platform from Innovaccer to create a centralized data and AI foundation across its network.The platform ingests and normalizes clinical data, claims data, medication records and real-time ADT feeds from multiple systems. It also uses an enterprise patient index to resolve patient identities across different EHRs and payer feeds.The organization then created what it calls a composite risk score, or CRS, designed to continuously prioritize patients according to clinical needs, financial risk, adherence behavior and social determinants of health.Each domain pulls from a different set of data inputs. Chronic conditions, HCC scores and recent admissions inform the clinical domain. Medication adherence and preventive care compliance contribute to the adherence domain. Transportation, housing, food insecurity and emotional needs influence the SDOH domain."We structure the CRS across four domains: clinical needs, financial needs, adherence needs and SDOH needs," Gerard said.The system continuously updates those scores and routes patients to the most appropriate discipline within a care pod. Patients struggling with medication adherence may be directed to a clinical pharmacist, while those with elevated social needs may be routed to a social worker."That domain-to-discipline routing is the operational mechanism that replaced our event-driven reactivity," Gerard said.Prioritizing care before a crisisToday, care teams open their patient panels each morning with risk scores refreshed continuously instead of relying on quarterly snapshots.The network currently has roughly 34,000 complex and chronic disease patients actively assigned to Care Team Pods. Care management staff are embedded in 33 practices serving both pediatric and adult populations.The same prioritization signals are used across multiple programs, including transitions-of-care teams, emergency department navigators, post-discharge follow-up programs and remote patient monitoring initiatives.Prisma Health also standardized social determinants of health screening in 2025 so positive screenings trigger centralized responses regardless of where a patient enters the system.More than 14,000 patients participate in remote patient monitoring and chronic care management programs focused on diabetes, COPD, asthma, hypertension and high cholesterol."The routing logic from CRS to service is something we have tuned over time inside Innovaccer based on what our teams have learned about which patients respond to which intervention," Gerard said.Results at scaleThe organization said the operational and clinical impact has been substantial.Among patients engaged in its Integrated Care Management cohort during 2024, Prisma Health reported a 66% reduction in total cost of care, a 75% reduction in admissions, a 70% reduction in readmissions and a 58% reduction in emergency department visits.Gerard said the scale of the operation made precise prioritization essential."When you have a five-discipline pod, you have to be exact about who they engage and which discipline leads," he said.The health system also saw strong outcomes in its remote patient monitoring programs for hypertension patients. Average systolic blood pressure dropped 21.6 mmHg, while average diastolic pressure fell 13.4 mmHg. Prisma Health reported that 92.5% of patients experienced reduced mean arterial pressure."For context, those are reductions that translate directly into lower stroke and cardiac event risk over time," Gerard said.Its Transitions Clinic program also reduced total cost per episode of care by 21% across post-discharge patients. Disease-specific reductions included 16% for COPD, 24% for sepsis and 29% for pneumonia.Winning physician trustGerard said one of the most important outcomes may not have been clinical at all.For years, provider engagement had been hampered by attribution models and quality calculations physicians did not fully trust. Prisma Health rebuilt those score cards so clinicians and care managers viewed the same patient records and quality measures calculated against a single standard.The organization also customized attribution logic so physicians saw the patients they were actually managing rather than patients tied to arbitrary calendar-year assignment rules.Once that happened, Gerard said, engagement rose sharply."Provider score card click-through engagement increased over 500% in a recent six-month window," he said. "If physicians do not open the score card, they do not act on the gaps, and downstream care management has to do compensatory work the system cannot sustain."For Prisma Health, the technology ultimately became less about dashboards and more about timing – identifying vulnerable patients before they become acute and directing the right resources early enough to change the outcome."That is the cultural shift behind the operational results," Gerard said.HIMSS is hosting the one-day AI Executive Leadership Summit in Boston on June 24, 2026, followed by its AI in Healthcare Forum June 25-26. Register separately for the two events here and here.Follow Bill's health IT coverage on LinkedIn: Bill SiwickiEmail him: [email protected]Healthcare IT News is a HIMSS Media publication.WATCH NOW: As AI evolves, it needs new oversight layers