Facilitate Access to Care Collaborate Across the Care Continuum Manage Financial Outcomes Understand Patient Population Practice Evidence-based Medicine Expand Reach Beyond Care Settings Deliver Patient-centered Care Address Non-medical Factors Adapt to Value Redesign Care Processes 01 Care Access 02 Collaboration 03 Patient-centered Care 04 Expanded Care 05 Evidence-based Medicine 06 Population Analysis 07 Financial Management 08 Non-medical Factors 09 Adapt To Value 10 Care Redesign 10 Care Redesign

Expand Reach Beyond Care Settings – Resource Library

  1. A Simple Way to Involve Frontline Clinicians in Managing Costs
  2. Accountable Care Organization Hospitals Differ in Health IT Capabilities
  3. ACO Beneficiary Engagement Toolkit
  4. Association of a Care Coordination Model with Health Care Costs and Utilization
  5. Association of Integrated Team-Based Care with Health Care Quality, Utilization, and Cost
  6. Breaking Down the Basics of Population Health Management
  7. Critical Lessons from High-Value Oncology Practices
  8. Delivering On Accountable Care: Lessons from A Behavioral Health Program To Improve Access And Outcomes
  9. Housing, Transportation, And Food: How ACOs Seek to Improve Population Health By Addressing Nonmedical Needs Of Patients
  10. Implementing a Hybrid Approach to Select Patients for Care Management: Variations Across Practices
  11. Medicaid Managed Care for Members with Mental Health Conditions and/or substance use disorders: Integrating Benefits and Care
  12. Robert Wood Johnson Foundation: ACO Evaluation
  13. The Characteristics of Physician Practices Joining the Early ACOs: Looking Back to Look Forward
  14. The Opportunities and Challenges of the MSSP ACO Program: A Report from the Field
  15. The Transformation to Value: A Leadership Guide

The following resource(s) may be of value:

  1. Beyond the EHR: Shifting payment models call for hospital investment in new technology areas
  2. Camden Group: Top-10 Characteristics of High-performing Healthcare Organizations
  3. Leveraging Risk Stratification for Population Health Management
  4. The Evolving Nature of Accountable Care: Results from the 2015 ACO Survey

Health Value Atlas

Expanded Care

Expand Reach beyond Care Settings

Organizational capabilities related to managing experience and outcomes outside of care setting

Note: Some organizational capabilities cross over to other domains. There may also be some degree of capability overlap with Health Equity Advancement, Continuous Quality Improvement, and Health Information Technology domains.

Use non-traditional locations

Deliver care at non-traditional locations

Use non-traditional partners

Deliver care through non-traditional partners, providers, and channels

Support patient self-care

Support patients in meeting their own health needs

Support caregivers

Support caregivers in meeting patient health needs

Provider patient incentives

Motivate positive patient behaviors with incentives

Anticipate health needs

Anticipate and address unspoken or emerging health needs

Educate patients

Educate patients about their health status and care

Engage patients

Engage patients in making informed decisions and participating in their own care

Communicate with providers

Communicate proactively with external providers

Provide home services

Deliver physical care at home as appropriate

Facilitate transportation

Address patients’ transportation barriers to care

Provide virtual services

Provide options for patients to receive services remotely

Automate data access

Automate timely access to data within and from outside the organization

Manage referrals

Manage patient referrals and appointments between providers

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