How Oak Street Health Engaged Post-Acute Providers To Improve Patient Outcomes and Experience

  • On-Demand Webinar

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View Oak Street Health’s Tej Motiwala and Jacquelyn Georgen as they discuss with Olio’s Ben Forrest how they brought together 245 skilled nursing facilities and home health agencies across Indiana to jointly co-manage their shared patients.

Oak Street + Olio

In this webinar you will learn about:

  • Oak Street Health’s transitional care program and efforts to improve post-acute care outcomes
  • Olio’s approach to facilitating bi-directional communication and collaborative discharge planning to seamlessly reconnect patients back to their primary care provide
  • The role of social work to proactively resolve social barriers to discharge to reduce length of stay and readmission rate
  • The importance of building strong, cross-continuum relationships with post-acute partners

Why it’s important

Post-acute care teams play a critical role in patient outcomes. Unfortunately, for care providers like Oak Street Health, the high volume of patients across post-acute care locations, including skilled nursing facilities and home health sites, combined with a vast partner network, presents a unique challenge in organizing, coordinating, and communicating across the continuum of care.

To deliver the best care outcomes for its patients and effectively support its network of care sites and partners, Oak Street Health, a network of value-based primary care centers for adults on Medicare, turned to Olio to solve this exact problem. Using Olio, Oak Street Health scaled engagement across 245 post-acute locations, reached a ratio of one Oak Street Health team member to every 99 post-acute users, and reduced readmissions for its patients.

Results Include:

  • 4x engagement per week per patient
  • 99:1 OSH to Post-Acute User Ratio
  • <10% RTA from SNF
  • 4 Day Decrease in SNF LOS
  • 7x ROI


  • Tej Motiwala is VP of Population Health at Oak Street Health, a national network of value-based primary care clinics for adults on Medicare. Tej partners closely with medical leaders on Oak Street’s admissions prevention strategy and oversees the transitional care and utilization management programs. He has also led several initiatives related to diversity, equity, and inclusion including a new process to capture patients’ self-reported race/ethnicity to more accurately measure and mitigate health disparities. Previously, Tej worked on clinical program design at CareMore Health, a subsidiary of Elevance Health, and payer and provider strategy consulting at Deloitte.
  • Jackie Georgen LCSW, CCM is the National Director of Transitional Care at Oak Street Health, overseeing a team of nurses and social workers that provide support to patients during and after admissions. She has held several roles at OSH since joining the organization as a Medical Social Worker almost eight years ago. Additionally, she has worked with individuals and couples as a clinical therapist and in the medical device business doing clinical research. Originally from the Northeast, she completed her undergraduate degree at Northeastern University and got her MSW from Indiana University.
  • Ben Forrest is the visionary CEO of Olio, a company empowering value based care organizations by bringing the care ecosystem together in one platform to streamline the co-management of patients and drive consistently better outcomes. With a solid healthcare background with industry giants like Stryker Corporation, Baxter Healthcare, and Medtronic, Ben’s journey from the medical device industry to the helm of Olio is one of purpose, resilience, professionalism, and fun. Ben and his co-founder are proud to be focused every day on improving the lives of hundred-of-thousands of complex patients across the country.

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