Patient-centered care is increasingly outpatient care and hospitals are approaching a once-unthinkable milestone: The American Hospital Association announced in January 2019 that hospitals’ revenue from ambulatory care nearly equals that of inpatient care.

The shift is going on not because of the federal government or cost issues, says Pat Merryweather-Arges, MA, Executive Director of Project Patient Care. It’s actually because patients prefer to utilize outpatient services, and she cautions that this high-speed change of care to ambulatory and other settings along the continuum, including people’s homes, poses real challenges for healthcare organizations, clinicians and the quality workforce.

“If anyone thinks that these silo-based value-based purchasing programs are going to continue, they’re not,” Merryweather-Arges says.

Raising performance in ways that improve quality and outcomes while controlling costs requires new thinking, new collaborative approaches and new capabilities to facilitate the continuing shift to value in healthcare.

Many ways forward

Successful population health models show different approaches for moving the needle on value and these three organizations that participated in the NAHQ National Healthcare Quality Summit in May 2019 illustrate the innovations that are emerging to successfully fulfill this need:

Advocate Aurora Health, one of the largest accountable care organizations (ACOs), is focused on clinical integration using a patient-centered medical home (PCMH) model for its thousands of affiliated and employed physicians. In targeting care quality, patient experience, care access and resource stewardship, the PCMH practices have contributed more than $10 million in savings and 5% improvement in cost of care for their commercial managed care population vs non-PCMH practices, Alvia Siddiqi, MD FAAFP, VP of Population Health Illinois, Enterprise Population Health, Advocate Aurora Health noted. For example, generic medication prescription by the PCMH practices rose from 87% in 2015 to 93% in 2017, with every percent increase delivering $1 million in savings, she said.

Oak Street Health provides primary care, supported by social and related health services, for adults on Medicare in high-density, underserved communities. With more than 60,000 patients, it is fully at-risk for the cost of care and has plans to expand from five to seven states and 40 to 53 centers. It uses a concierge care model that includes complimentary transportation, house calls, dedicated care teams, no wait/same day appointments and access to related services such as podiatry and behavioral health. To encourage engagement, its stand-alone centers have community space with computer labs, self-service cafes and event space. This approach has driven down hospital readmissions by 45%, Emergency Department visits by 52% and 30-day readmission rates by 35%, said Caroline Sommers, MPH, Oak Street Health’s Senior Vice President of Clinical Quality.

Project Patient Care is involved in the Centers for Medicaid and Medicare’s massive, multi-year effort to prepare more than 140,000 clinical practices for value-based care and population health management. CMS’ Transforming Clinical Practice Initiative is aimed at improving a wide range of quality, operational and clinical issues. “Where the patients are engaged and involved, there’s where we are seeing them making great headway in performance, outcomes and in all the measures you really want to excel,” said Merryweather-Arges.

Key success factors

Population health upends traditional relationships, roles and processes among providers, patients and quality professionals. Some proven strategies for making the transition include:

Sharing decision making with patients

Focusing on prevention and wellness, improving outcomes and meeting other key performance goals for population health require active patient participation. That’s not just on the front lines, but in setting strategy and priorities, including quality and performance improvement efforts. Patients must make up at least 51% of the boards for federal qualified health centers and Medicare ACOs are required to have at least one beneficiary on the board, Merryweather-Arges noted.

Finding common ground to achieve Quadruple Aim

To promote standard best practices and elevate clinical and financial performance across the ACO, Advocate requires all member physician practices to adopt the PCMH model, common data registry and common electronic health record system, explained Siddiqi. “This is a leverage we use to transform that quality language and discussion within the practices,” she said.

With leadership from NAHQ, quality professionals should take the lead in getting all stakeholders on the same page, Merryweather-Arges says. “The challenge that we face right now is we talk different quality improvement and performance improvement languages. That’s where NAHQ comes in with its twice-validated industry-standard competency framework. That’s the opportunity to really make sure if you’re working on performance improvement that it goes across the continuum,” she said.

Leveraging data to drive improvement

Oak Street Health has created a propriety data platform that structures and monitors every element of care. Everyone from physicians to call center reps use the intuitive tool for actionable insights that guide them to deliver the right work at the right time. “We want to be able to take the typical person that’s available in the workforce, the typical MA, the typical provider, and bring them into our model and enable them to actually provide consistent and high-quality care,” explained Sommers. “This is what really allows us to execute consistently and makes our care model come to life.”

Quantifying and promoting the ROI of quality work

“Telling your story through value reports,” including case studies, industry awards and more, is essential, Siddiqi said. “Calculate the ROI from your quality improvement,” she said, but don’t stop there: “Publicizing your work both internally and with payers is really important.”

Investing in workforce training and development

Oak Street Health offers a range of ongoing education and training, including quarterly e-learning options, monthly leadership huddles and enrichment sessions by cohort, such as social workers. “Training is such an important component for us that we actually shut down our care centers to dedicate time to train our full care team members,” said Sommers.

Continuing to innovate

Advocate’s PCMH program is moving to a new phase in which the ACO is seeking to draw in other practitioners and care programs, starting with a pilot involving four pulmonology practices. “The work we’re trying to do is not just to transform primary care but how do we transform that whole medical neighborhood including specialty practices,” noted Siddiqi. It’s also updating key performance measures, which in part determine incentive-based physician compensation, to reinforce the need for both individual excellence and collaboration.

To learn more about competency-based training and workforce development, please contact NAHQ at

– Pat Merryweather, MA

Executive Director
Project Patient Care

– Caroline Sommers, MPH

Senior Vice President of Clinical Quality
Oak Street Health

– Alvia Siddiqi, MD FAAFP

VP of Population Health Illinois
Enterprise Population Health
Advocate Aurora Health

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