1. Risk Assessment Factor (RAF) score.
2. Hospital utilization.
3. Preventing Readmissions via better care transitions
4. Active management of high need/high cost patients
5. Manage/reduce post acute care spending
6. Increase referrals to ACO based providers/reducing leakage
7. Integrate behavioral health care into primary care settings
8. Medicare Shared Savings Program (MSSP)
9. Social Determinants of Health (SDoH)
