Care transitions redesign as an innovation incubator at a regional academic medical centre

The ongoing transition by federal and commercial payers from fee-for-service to value-based reimbursement increases the need for sustainable and scalable high-performing ambulatory care management programmes to support patients across the continuum of care. In this paper we describe one health system’s approach to integrating distinct care management programmes into one aligned structure and standardising best practice workflows. We established and implemented organising principles for the restructuring, including standard documentation, reducing the burden on clinicians, transparently measuring both process and outcome measures and optimising the use of technology solutions. We internally validated and then applied risk stratification rubrics within the electronic health record to stratify our patient population and calibrate the intensity of our care management models based on patient clinical risk. Risk stratification, standardisation of work and introduction of automated outreach allowed the team to increase call volumes, maintain a 77 per cent connection rate to patients post discharge and create a new chronic care management programme without an increase in the number of full-time equivalent (FTE) roles. Important lessons learned include the importance of clearly communicating changes and performance to front-line clinicians and leadership; and garnering feedback from stakeholders to guide continuous optimisation of our standardised workflows. This article is also included in The Business & Management Collection which can be accessed at https://hstalks.com/business/