Far too often analytics efforts have fallen short of making a tangible impact on outcomes because they haven't been successfully implemented in real workflows. Predictive models remain at risk of becoming isolated in their use along the continuum of care where their integration may provide benefits larger than the sum of each silo. UnityPoint Health (UPH) focused on integrating analytical models within the same readmission reduction strategy and coaching the care team to facilitate their adoption. Using this approach, one of UPH hospital's risk-adjusted readmission index improved 40% over three years, surpassing internal system targets in performance and becoming the top performer in the health system. This session will provide an overview of the analytics tools and methods UPH used, including innovative individualized risk heat-maps generated for each patient, strategies for analytics adoption, and lessons learned along the way.