After analysis of Oncology Care Model data identified three comorbid illnesses that led to significantly higher rates of unplanned emergency department (ED) visits and hospitalizations—COPD, congestive heart failure, and diabetes mellitus—Tennessee Oncology developed targeted management algorithms that proactively addressed these conditions. Today care coordinators use these algorithms to screen, identify, and help manage at-risk patients via the care management platform, either by patient-initiated contact, such as telephone triage, or through a patient health portal, depending on the patient’s access and comfort with this technology. For patients admitted to the ED or hospital, admission software provides real-time data to the practice to improve patient management and reduce length of stay and readmissions.