1. Use quality improvement methods to support ongoing improvement of the enhanced care model.
  2. Scale up services to all people in your population with complex needs and high health care costs.
  3. Plan for sustainability from the beginning.

1. Use quality improvement methods to support ongoing improvement of the enhanced care model.

Use quality improvement methods to help your organization understand if your enhanced care model is meeting its desired outcomes and operating well, and to guide ongoing learning towards improvement. Establishing a “learning system” that embraces iterative learning, outcome and process measures to guide the work, and effective communication among stakeholders will fuel ongoing dialogue that supports growth and sustainability of the enhanced care model.

Use process measures, outcome measures, and patient stories to evaluate and improve performance, and build evidence that your enhanced care program is achieving the desired results.
Develop an explicit theory or rationale for how your enhanced care model will improve outcomes for your population.
Use a structured approach to guide your improvement work.
Provide effective project management, with regular oversight and guidance from leadership.
Tips and guidance for using quality improvement methods:
  • Collect a mixture of quantitative data (e.g., numeric) and qualitative data (e.g., verbal/textual) to learn how well your enhanced care program is working.
  • Involve payers, organizational leaders, providers, and patients in continually improving the program. Seek their input on how to refine the program to better achieve desired outcomes.
  • Create opportunities for patients and providers to help redesign care, including designing initial tests of change and studying the tests’ results to determine whether a change is an improvement.
  • Consider organizing your logic model or driver diagram around resources and inputs (such as key stakeholders and partners, technology and supporting infrastructure, and regulatory and compliance issues); program interventions and activities (such as project management, evaluation, and pathways to identify, engage, partner, and care for people with complex needs and high health care costs); and short-, intermediate-, and long-term outcomes.
  • Develop a score card that displays outcomes and process measures for the enhanced care program.


“We are constantly monitoring the effect and production of our teams through visual management boards and metrics that we follow. We have goals that we set for the program. We’re constantly refining it and taking the lessons we’re learning to try to improve the work we’re doing. This gives the executive team confidence that we are not just in status quo mode. We do an annual evaluation of the program and we look at utilization trends for the population we are serving. We also do an annual provider survey. It’s not like [the program is] just left alone on autopilot.”Rebecca Ramsay, BSN, MPH, Executive Director, Population Health Partnerships, CareOregon

2. Scale up services to all people in your population with complex needs and high health care costs.

There is a need to move from testing the delivery of services with a small group to delivering these services efficiently to all people in the target population who would benefit from them. The testing phase focuses on trying out or adapting new ideas to learn what works in your system. As you grow your interventions from 5 to 25 individuals, and are confident that the interventions are impactful, move to implement. Implementation focuses on making a change a permanent part of the day-to-day operation of your system. Often programs are ready to go to scale after serving between 25 to 125 people. As the scale of testing is increased, previously unknown system constraints and opportunities for efficiency can be discovered and addressed.

As you move to scale, you will need to engage people in your enhanced care model; develop efficient processes; have providers adopt the workflow and care processes associated with your enhanced care model; and develop strategies to overcome structural issues that arise when moving to scale. Follow the three steps below to help you move toward full-scale implementation of your enhanced care model

Determine what full-scale implementation of the enhanced care model entails at the outset, and track your progress relative to established milestones for serving all people with complex needs and high health care costs in your target population.
Address structural issues that require expansion to match increasing scale.
Tips and guidance for scaling up services to all people in your population:
  • Develop a formal system to share successes and challenges as the scale increases.
  • Share goals, visual boards, and updates of work in progress with your business team and executives to stay informed of ongoing program management.
  • Use PDSA cycles and continue to plot data over time to learn what is needed to standardize changes to your enhanced care model.
  • Agree up-front with your payers on a business plan that leads to sustainability and scale.
  • Anticipate increasing scale to avoid downstream problems in hiring additional staff or securing other resources.


“In our enhanced care program, we are using the patient activation measure, or the PAM tool. So far we have trained about 50 people in how to use it. As we look at scaling the program, we’re starting to look at it in an organized way — looking within specific work groups and departments and thinking through who we will give the tools to do it, what will we do with the results, how will we document it in our electronic record. Overall, we’ve been trying to take a very organized approach so that we can measure our results and develop a scalable program. One of my concerns is, looking at other programs, they’re not necessarily designed in a way to scale up. Ultimately we need a program that’s going to work for all of the patients with complex needs and high costs within our total population.” Diane E. Craig, M.D., F.A.C.P, Assistant Physician-in-Chief, The Permanente Medical Group, Santa Clara Medical Center

3. Plan for sustainability from the beginning.

Create a sustainable enhanced care model for your population.
Cultivate ongoing investments to enable a sustainable enhanced care model for your population with complex needs and high health care costs.
Meet with your four key audiences to learn what matters most to them and to create shared expectations around value.
Develop the value statement for your enhanced care model and identify different ways of calculating return on investment (ROI).
Tips and guidance for planning for sustainability from the beginning:
  • Set aside and schedule time to do the work needed to engage all groups of key stakeholders. Organizations have found that it often requires equal amounts of work to engage payers, institutional leaders, providers, and patients.
  • Understand trends from management’s perspective. Learn what matters, and whether you are on the right track with the metrics that top leaders will need to see to make a sustainability decision.
  • Use storyboards to inform health system leaders about the status of the program relative to goals and milestones. Review an example of a storyboard from Winnipeg Regional Health Authority.
  • Consider creating and sharing brief videos (5 to 10 minutes) that convey patient narratives. Identify the message you want to convey; choose the right clients; prepare patients to focus on parts of their stories that would be compelling for stakeholders; and choose a videographer that understands the message.
  • Financial ROI can be difficult to achieve, but many organizations are facing increasing pressure to be cost neutral.