Executing Successful Change

How do we successfully redesign and improve our enhanced care model? How do we take it to scale, and plan for sustainability?


“In my experience, most places start out overfunded. They overhire, overpromise, and overbuild. There are two approaches to try to resolve ambiguity. One approach is to do deep and profound planning, spend a lot of money, hire and create an organizational chart and structure — classic planning. The other way is a more lean start-up, where you build around an n-of-1, n-of-5, n-of-10, and build in response to the customers — really doing a root cause analysis and clarify the problem you are trying to solve…


It’s hard to create the team-based structure to support the work. It’s hard to identify the right patients. It’s hard to engage the right patients. It’s hard to understand the ecosystem of social behavioral health services that these patients are interacting with. Every single piece of the work is hard.” Jeffrey Brenner, MD, Executive Director, Camden Coalition of Healthcare Providers

Why is this important? And what do we know?

  • Wholesale adoption of best practices and enhanced care models that work in one context are likely to fail in another context. There is no recipe or one-size-fits-all enhanced care model. The enhanced care model will be impacted by the needs of a specific population, organizational structure, community setting, financial incentives, and strategic priorities.
  • Organizations with successful enhanced care models use human-centered design and robust quality improvement methods to tailor best practices and good ideas to their local context. The Care Redesign Guide draws from the experiences of organizations working with various populations with complex needs and high costs to provide ideas on how to structure enhanced care models, identify patients, engage patients in new ways, and build relationships with new types of partners.
  • Executing successful change is hard work, and the time-frame often spans three to five years before organizations begin to see promising results from their efforts to redesign care for populations with complex needs and high health care costs. Yet, successful execution directly impacts an organization’s ability to reach its aims to provide better outcomes at lower costs for the population segment with complex needs and high costs and to sustain the enhanced care model over time.
  • Organizations that can execute successful changes and continually improve performance have the following capabilities in common:
    • Ability to align the enhanced care program with the aims, vision, mission, and values of key stakeholders. This can help your organization leverage its strengths, find opportunities to partner, and proactively explore potential return on investment.
    • Ability to allocate staff and money to achieve aims that align with the organization’s strategic priorities.
    • Strong local management and supervision of the activities needed to improve care.
    • Continual development of the capacity and capability of staff to understand quality improvement and lead the initiatives needed to achieve system-level results.
  • Organizations that are successful in sustaining improvement have the following capabilities in common:
    • A focus on the daily work of frontline managers.
    • A high-performance management system that prescribes standard tasks and responsibilities for managers at all levels of the organization.
  • This module outlines foundational methods for using quality improvement methods, scaling up services to those who need them, and planning for sustainability.

Core recommendations

Use quality improvement methods to support ongoing improvement of the enhanced care model.
Scale up services to all people in your population with complex needs and high health care costs.
Plan for sustainability from the beginning.
  • Enhanced care models for populations with complex needs and high health care costs typically use more resources than traditional care, are challenged to demonstrate cost savings, and usually have a three- to five-year development timeframe. Program champions and staff need to work consistently to cultivate support and interest in the enhanced care program from four key audiences: the organization that pays for health care delivery, the organization from which the program derives resources, the medical community from which the program receives referrals, and the patients whom you seek to enroll.
  • Detail to plan for sustainability from the beginning.

How to get started executing successful change

  • Start testing elements of your care model with a small number of patients (e.g., five patients).
  • Begin tracking outcomes with your first five patients, and build your measurement infrastructure as you work with the next 25, 125, 625, and so on (i.e., using the multiples of 5x method to expand the work to more patients in the population).

Overall tips and guidance

  • In this Care Redesign Guide, we outline a 5x method to begin learning on a small scale, learning deeply about what will work and then scale-up by multiples of 5. Start with five patients and strive to give perfect care, then expand the enhanced care model to 25 patients, then to 125, and up. Embrace this method and become good learners.
  • Commit to developing the organizational leadership and team infrastructure to learn and improve well together. The following resources provide good guidance: Execution of Strategic Improvement Initiatives to Produce System-Level Results and Pursuing the Triple Aim: The First Seven Years.
  • Engage with key stakeholders early in your work. They will need time to understand your enhanced care model and carve out the financial and human resources needed to support this work.