Bookmark Medical focuses care management on its most actionable MSSP members
Bookmark Medical supports value-based primary care practices across multiple states. With Radial's AI care orchestration and next-gen business intelligence, its care teams shifted effort from high-risk patients to actionable ones, and leaders gained a clear view of what drives avoidable utilization.
65,000+ MSSP members
Multi-state population
Daily prioritized worklists for care managers
The challenge: care teams can't reach every patient
Value-based care organizations succeed by delivering high-quality care while keeping patients safely at home. Avoidable admissions and readmissions, prolonged skilled nursing facility (SNF) stays and unnecessary post-acute facility care are among the biggest controllable cost drivers.
Bookmark Medical set out to reduce readmissions and SNF length of stay for its Medicare Shared Savings Program (MSSP) population. But like most care management teams, its care managers were spreading their effort across many high-risk patients, and many of those patients weren't actually actionable. The result was excess 30-day readmissions, SNF utilization and prolonged SNF stays.
The real question wasn't "who is high-risk?" It was "who is high-risk and actionable, and what should we do next?"
The solution: AI care orchestration plus next-gen business intelligence
Radial gives care managers and executives one connected system, in which insights flow down to care teams and results flow up to leadership.
For care managers: every morning
- Prioritize: a daily worklist ranked by Radial's actionability score for readmissions and SNF length-of-stay opportunities
- Understand why: patient-specific explanations of why each person was flagged, including clinical, functional and social risk factors
- Act: suggested next best actions, plus guidance on the right touch and timing for outreach
- Close the loop: arrange home services and follow-up, and keep patients, caregivers, PCPs and specialists aligned
For clinical executives: business intelligence for strategy
- Find opportunities: see which diagnoses, hospitals, SNFs and providers drive avoidable utilization
- Benchmark: compare the ACO against regional and national peers on clinical and operational metrics
- Sharpen focus: set the priority diagnoses, facilities and cohorts for care teams
- Ask in plain language: instead of static dashboards, leaders ask questions and get synthesized answers, recommended next steps and proactive weekly briefs
| Traditional BI | Next-gen BI |
|---|---|
| Static dashboards | Ask questions in plain language |
| Siloed, retrospective reports | Unifies clinical, operational and cost data |
| Users interpret the charts | Explains drivers and curates next steps |
| Log in to look | Pushes insights to leaders |
In practice: re-engaging a hard-to-reach member
One Medicare ACO member had repeat readmissions and had been hard to engage consistently.
- 1
Identify
Using readmission risk and utilization history, including chief complaints and prior hospitalizations, Radial flagged him as a high-yield, actionable opportunity.
- 2
Coordinate
An interdisciplinary team (RN care manager, visiting nurse services, PCP, and elder services) worked out the best ways to connect with him.
- 3
Outcome
He engaged consistently, accepted several of the resources offered, and his readmission rate went down.
"It was a great example of how teamwork and persistence can lead to better support for a patient."
What the Bookmark Medical team says
Supporting them in this way helps them remain healthy, safe, and independent at home.
I use it every day to find additional referrals to assign to my team.
Radial always has the information I need, other platforms don't.
I especially like the valuable insights on readmissions and each member's utilization history.
The impact
- Focusing care management on the most actionable patients and urgent interventions, not just high-risk members, has been shown to reduce readmissions and avoid unnecessary SNF days.
- Explainable insights and next best actions help care managers act quickly and get the care team aligned on concrete steps.
- Business intelligence shows leaders which diagnoses, hospitals, SNFs and providers drive avoidable utilization, linking value-based care strategy to day-to-day execution.
What's next
Radial and Bookmark Medical are expanding the partnership by bringing self-service business intelligence to more clinical and operational leaders. They are also moving beyond readmissions to avoidable admissions, prioritizing chronically ill, socially complex and palliative- or hospice-appropriate members for home-based care, and extending the approach to Medicaid ACO and Medicare Advantage programs.
As presented at the American Academy of Home Care Medicine (AAHCM) 2026 Annual Meeting
Anant Vasudevan, MD, MBA (Radial) and Haley Claflin, MA, BSN, RN (Bookmark Medical)
Radial technology development was funded in part by the National Science Foundation and the National Institutes of Health. Patient example is de-identified.
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