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Innova Population Health

Connecting People and Teams

Population health and value-based care (VBC) require more than participation in new CMS and commercial models—they require teams that can execute day to day across transitions, chronic care, and continuous data. 

Every avoidable ED visit, readmission, or missed escalation can erase margin, so staffing strategy matters as much as technology. 

INNOVA Health connects organizations with population health and VBC professionals who turn data into action, align workflows to contracts, and improve clinical and financial performance. 

  • Reduce avoidable utilization by strengthening transitions of care and escalation pathways. 
  • Turn EHR, claims, SDOH, RPM, and wearable data into workflows and outreach, not just dashboards.   
  • Build longitudinal care teams aligned to risk-bearing contracts and quality measures. 

What we help your teams execute: 

  • Reliable transitions of care from hospital to SNF or home, with clear ownership and follow‑up.   
  • Data operations that convert EHR, claims, SDOH, RPM, and wearable signals into registries, escalations, and closed‑loop workflows.   
  • Longitudinal, patient‑centered care that actually aligns frontline work with risk‑bearing contracts and quality measures. 

We specialize in placing leaders and frontline professionals in roles that determine whether VBC initiatives succeed—or quietly lose margin—across programs like LEAD and TEAM. 

Complementing our team-building expertise, INNOVA Analytics Advisory Services – delivered alongside Datalion and HealthCorum – enables organizations to operationalize data, align performance metrics, and drive measurable clinical and financial results. 

Executive & Strategic Roles We Place:

  • Owns population strategy across CMS, ACO, and commercial value‑based contracts 
  • Aligns attribution, panel definitions, and risk stratification with operational reality 
  • Partners with finance to tie Pop Health and Ambulatory clinical programs (care management, RPM, SDOH) to total cost of care and shared‑savings performance 
  • Translates VBC requirements and KPIs into concrete financial and operational workflows 
  • Works with operations and IT so that what’s in the contract is actually measurable, manageable, and billable 
  • Integrates EHR, claims, and continuous data (including RPM, ambulatory visits, and data from wearables) into proactive course correction rather than reacting to avoidable ED visits and admissions 
  • Builds and refines escalation rules: who gets called today, who needs a visit this week, who is failing at home 
  • Partners with frontline clinicians to ensure alerts are clinically meaningful and fit into workflow – not just another unused dashboard 

Pharmacists, NPs, and PAs 

  • Own high‑risk transitions: med reconciliation and adherence across the 30‑day post‑discharge window and beyond 
  • Lead chronic disease care management (HF, COPD, diabetes, CKD) using multiple communication channels and continuous data trends to catch deterioration early 
  • Close care gaps that directly drive readmissions, ED utilization, and missed quality metrics 
  • Address transportation, food security, home safety, and caregiver support that determine whether discharge plans are realistic or aspirational 
  • Coordinate with community‑based organizations and payers to operationalize SDOH benefits 
  • Feed structured SDOH, home‑visit, and caregiver‑input data back into the integrated patient record so clinical teams see the full picture 
  • Translate complex care plans into what patients and families actually do day‑to‑day 
  • Use data (including RPM and wearables where appropriate) to support self‑management—sleep, activity, medications, and symptom monitoring 
  • Reinforce behaviors that reduce avoidable care over the full episode 

INNOVA Health understands the operational shifts required to succeed in risk‑bearing value‑based care. 

Building Infrastructure for Long‑Term Success 

INNOVA Health understands the operational shifts required to succeed in risk‑bearing value‑based care. We go beyond filling roles—we help you build infrastructure for long‑term success: 

  • Design the right mix of skills and reporting lines for tech‑enabled, longitudinal care.   
  • Hire leaders who can align incentives across service lines, not just run siloed pilots.   
  • Stand up teams that know how to turn new care plans and reimbursement models into better outcomes and predictable financial performance. 
Ready to operationalize value‑based care with the right team in place? 

Partner with INNOVA Health to secure top‑tier population health and VBC talent and build the infrastructure for sustainable performance across your organization. 

Contact: Dr. David Gorstein, Partner & Practice Leader | 843-670-0991 | [email protected] 

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