From Spreadsheets to Shared Success:

The Challenge

As MCHN’s network and contracts expanded, the complexity of managing care and data grew exponentially. Each participating health center had its own EHR, care management tools and documentation workflows, creating silos that made it difficult to track patient progress, align quality measures, or demonstrate value to payer partners.

Another critical factor driving the need for a unified solution was MCHN’s growing role in managing funding and reporting for Community Health Worker (CHW) programs. Under several Medicaid value-based contracts, health plans provided payments to the CIN to support CHW services but MCHN needed an effective way to direct and prioritize that work across member health centers.

“Without a shared view of the data, we couldn’t see how all the pieces fit together, or where we needed to focus support.”

Samantha Fisher, Director of Patient Services & Engagement at MPCA

The network also had to aggregate and report back on CHW activities to the health plans, demonstrating both volume and quality of outreach being performed to justify payments. Without a centralized system to coordinate efforts or monitor outcomes, tracking impact and maintaining accountability across sites became increasingly challenging.

Care teams were spending too much time searching for information instead of acting on it. Data lived in multiple applications and systems, requiring manual entry and duplicative reporting to satisfy health plan requirements.

“We were using a number of different documentation systems, entering the same information several times with limited automation or integration,” said Samantha Fisher, Director of Patient Services & Engagement at MPCA. “Without a shared view of the data, we couldn’t see how all the pieces fit together, or where we needed to focus support.”

Network leaders needed a unified view of performance, while frontline care managers needed tools to streamline communication, close gaps, and coordinate care across the continuum. The result was a growing operational strain. For a network built on collaboration, success required something bigger than individual fixes, it required a shared infrastructure for data, documentation and accountability. 

The Solution

To tackle the fragmentation across systems and workflows, MCHN and MPCA deployed Azara Care Connect (ACC), a care coordination and care management platform designed to unify complex, multi-site networks around shared data and accountability.

Built on Azara’s Best in KLAS DRVS platform, ACC extends insights into action by enabling real-time coordination, task management, and performance tracking across participating health centers to collaborate within a single, web-based environment. The platform integrates data from EHRs, HIE feeds and claims sources to automatically surface care opportunities, assign follow-up tasks, and support standardized workflows for care management, transitions of care, and chronic disease management.

MCHN worked with Azara to tailor the implementation around the network’s existing DRVS infrastructure and payer contracts. Each participating center gained access to shared tools and dashboards but retained flexibility to adapt workflows to their local teams. The platform’s automation and task management features reduced duplicative work while improving visibility into who was doing what across organizations, roles and programs.

By connecting previously siloed systems, Azara DRVS combined with Azara Care Connect gave the network a single platform to view and manage the full continuum of patient care.

“What used to take days of reconciling spreadsheets now happens instantly,” said Sarah Gonzales, RN, Clinical Quality Manager at MPCA.

With a unified, data-driven foundation in place, MCHN and MPCA are now better positioned for the next stage of value-based transformation: aligning people, processes, and data under a single model for population health management.

The Results

With Azara Care Connect, MCHN transformed fragmented care coordination at scale, into a unified framework, spanning more than three dozen health centers, 10 EHRs and thousands of patients under value-based contracts. The platform’s integration with Azara DRVS created a shared infrastructure that improved efficiency, accountability, and outcomes at every level of the network. 

Streamlined Transitions of Care:

Before ACC, post-discharge follow-ups often lagged by days due to manual notifications and incomplete data. Now, alerts for emergency department and inpatient discharges flow directly into the system, allowing care teams to respond in real time. This shift from manual to real-time notifications has translated into meaningful performance gains across the network: 

• 60–70% of Medicare inpatient admissions and discharges are now captured statewide
• Automated task assignments ensure no patient is overlooked while reducing duplicative outreach 
• Greater patient engagement and faster gap closure across participating health centers
• 9% increase in follow-up call completion post discharge

Medicaid Redetermination Impact

In 2024, Michigan centers that used ACC to conduct targeted outreach to Medicaid members needing enrollment assistance retained 7% more members than those that did not (57% vs. 50.6%). Across the statewide network serving over 155,000 Medicaid beneficiaries, this difference represents thousands of individuals maintaining uninterrupted access to primary care.

The financial impact for the network was substantial: keeping 9,300 patients engaged helped prevent $4 million in lost revenue from just a single visit, with potential to scale to $20 million annually based on average patient utilization. By integrating enrollment support into daily workflows with Azara Care Connect, MCHN enhanced care continuity, boosted contract performance, and prevented substantial revenue loss. 

Empowered Care Teams:

Care managers, community health workers, and nurses now work from shared, customizable templates that mirror their local EHR workflows, reducing double documentation and easing onboarding for new staff. Built-in screenings such as the CTM-15 and Medicare Annual Wellness Assessments ensure consistency across programs and funders.

Together, these workflow improvements have translated into tangible operational and patient-care gains: 

• 70% reduction in time spent on reporting and data normalization 
• Reduced documentation anxiety 
  
• Staff have real-time visibility into their impact via task tracking and closure reports

"The information is right there, and we can act immediately. That speed has completely changed how we support patients in transitions of care."

Sarah Gonzales, RN, Clinical Quality Manager at MPCA

Network-Level Oversight:

With shared governance, consistent documentation, and a single view of performance across all value-based contracts, MCHN turned data into a unifying force rather than an administrative burden. 

• Unified, payer-agnostic workflows reduced variation across 10 EHR systems 

• Shared costs and development funded through network savings created a sustainable adoption model. 
• MPCA’s central support structure ensures alignment with ACO MSSP, Medicaid and other program measures. 

These results have done more than streamline reporting—they’ve created a durable foundation for future innovation. MCHN is now expanding ACC to behavioral health and community-based partners, building the next generation of whole-person, value-based care. 

Looking Ahead

With Azara Care Connect now embedded across the network, MCHN and MPCA have created a durable foundation for coordinated, value-based care. What began as a response to fragmented data and duplicative effort has evolved into a unified infrastructure that connects payers, providers and patients around shared goals.

Building on this foundation, MCHN and MPCA are now turning their attention to the next phase of transformation: deepening analytics, expanding interoperability, and broadening participation across behavioral health and community partners.

Upcoming priorities include automating additional value-based reporting and leveraging shared insights to advance statewide quality improvement. By continuing to invest in connected infrastructure, the network is ensuring that every Michigander benefits from consistent, data-driven, whole-person care.