Square6 Group worked with executive and cardiology leadership at Christiana Care Health System (CCHS) to develop and co-author a successful $10M Centers for Medicare and Medicaid Innovation grant to improve the care and outcomes of heart attack patients. The program, called Bridging the Divides, will create the Care Hub at CCHS - comprised of a data layer, patient management tools, evidence based protocols and care methods in conjunction with a cost-effective new clinical team comprised of RNs, social workers and health coaches. The overall goal is to reduce 30 day readmissions for heart attack patients and improve their long-term outcomes. Square6 Group was integral in the grant, program architecture and requirements, and execution.