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.
  • Establish robust population- and program-level measures.
    • Use population-level outcome measures for health outcomes, cost, and patient experience. Track these measures for your target population and the full population, if possible.
    • Identify a set of process measures that you can track over time.
    • Establish a mechanism to collect data for process measures, outcome measures, and patient stories as part of the daily work. Build assessments into the flow of care. For example, some organizations ask patients to complete a brief health survey before every care visit; other organizations survey health care providers on a quarterly basis to assess satisfaction with the enhanced care model.
  • Use your data to guide your work.
    • Use data in run charts to show change over time in selected process and outcome measures. Review these charts with key stakeholders in regular (e.g., weekly, biweekly, monthly, bimonthly, etc.) meetings. Build up your data systems to track measures for the patients engaged in your enhanced care model, and for your population with complex needs and high health care costs.
    • careoregon-dataReview the early data system and evolution of Care Oregon’s Health Resilience Program. As they learned their way to the enhanced care model design, and the data needs, their systems became more sophisticated.
    • Regularly collect stories (both successful and not successful) from patients, program staff, and providers to identify strengths of the enhanced care model and opportunities to improve the model. Identify common themes about what is working well, and ways in which the program could be improved.
  • The IHI Better Health and Lower Cost Collaborative (BHLC) used the following measurement strategy with participating teams, who then customized their measurement strategy to their local context:
Outcome Measures(examples)          Process Measures (examples) Patient Stories (examples)

Health Outcomes:

  • Self-rated health status


  • ED and inpatient utilization measures

Patient Experience:

  • Survey of an individual’s experience in the enhanced care program
  • Patient confidence in their ability to manage health; or patient activation
  • Number of individuals recruited into the enhanced care model
  • Percent of individuals engaged in the care model
  • Frequency of meaningful contact between patients and providers or the care team (i.e., documented two-way conversation or correspondence)
  • Number of individuals working with a health coach or some other key service
  • Percent of individuals who have completed the enhanced care program
  • Number of individuals on active caseload
  • Throughput of individuals
  • Percent of full-scale population served by the program
  • Comparison of an individual’s lifestyle and health status before and after engaging in the enhanced care program
  • Patient story of how the enhanced care model is different than other models of care, and why this is important to them


Develop an explicit theory or rationale for how your enhanced care model will improve outcomes for your population.
  • Use multiple sources of information to develop an explicit theory that supports your enhanced care program. Learn from the suggestions in this Care Redesign Guide, the literature, site visits to other organizations, reading case studies, and from your study of the needs and assets of your own target population.
  • Capture the theory on paper using a driver diagram or logic model. Use this Care Redesign Guide to develop your theory and identify gaps in the design of your enhanced care model.
  • Refine your theory over time, based on continued learning.
Use a structured approach to guide your improvement work.
  • Use principles of human-centered design to develop your enhanced care model. This includes defining the goals and needs from the patients’ perspective, understanding the context in which care is currently delivered, developing a shared concept for how a new care model might be delivered, and pilot testing and refining the enhanced care model. Stanford Coordinated Care, an ambulatory Care ICU, used a design process to design their enhanced care model.  Review this resource of their design process.
  • Use principles of the science of improvement to guide your work. Identify and use a quality improvement method and develop deep expertise in its use. IHI uses the Model for Improvement, but other improvement methods and approaches exist.
  • Use the 5x method to redesign care and grow it to full scale. Work deeply with five patients to learn what interventions are needed and how they need to be delivered. Grow the redesigned care model to caring for 25 patients to confirm the interventions and continue testing, to define staff roles, workflows and data collection. When confident the enhanced care model is designed to meet your aims, begin to grow to full scale in jumps of 5x-from 25 to 125 patients; from 125 to 625 and up.  Learn in each 5x jump how to overcome the structural issues that arise when moving to scale.
  • Use principles of co-production to involve patients and providers as co-designers of your enhanced care model.
  • Use iterative testing, such as Plan-Do-Study-Act (PDSA) cycles to identify the interventions and care model most likely to be impactful, and to continue to refine your program over time. Review examples of PDSA cycles from teams in the IHI Better Health and Lower Cost for Patients with Complex Needs Collaborative. 
  • Plot data from sequential testing of small changes to quickly show which changes are effective, and which should be abandoned. When you learn that an intervention has a positive impact, use PDSAs to reach more people with the intervention, making necessary adjustments as indicated by the results of the further PDSAs.
Provide effective project management, with regular oversight and guidance from leadership.
  • Designate a project manager to oversee the improvement efforts. Examples of tasks that a project manager oversees include:
    • Create an implementation plan and timeline.
    • Regularly assess progress relative to stated goals.
    • Assign tasks and responsibilities to staff and hold them accountable to these activities.
    • Establish and use regular communications between the improvement team and leaders to ensure shared understanding of program progress, and ongoing alignment between the program and its key stakeholders.
    • Establish formal opportunities for those working on the enhanced care model to share learning. Examples include conducting monthly sharing sessions among care managers to discuss successes and challenges, and to formalize care processes that can be used by all care managers.
    • Meet regularly with improvement team members to discuss current status, work in progress, and do action planning.
    • Meet regularly with project leaders to discuss successes and challenges, and to identify strategies to overcome barriers. 
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.

Full scale is defined as the total number of people who could benefit from your enhanced care model. Knowing how many people your program needs to serve helps program staff and leaders understand the full opportunity, set sights on longer term goals, and establish milestones to achieve these goals. Use the following strategies to determine full scale:

  • If you have an enrolled population, typically a group of individuals receiving care within a health system or whose care is financed through a specific health insurance plan or entity, use claims or other data sources to calculate full scale.
    • For example, if your target population is the top 5 percent of high-risk, high-cost Medicaid beneficiaries, then full scale is 5 percent of your total Medicaid population. To illustrate this, imagine that your organization cares for 160,000 Medicaid beneficiaries. Calculate your full-scale population using the following formula: (Total number of Medicaid beneficiaries: 160,000) x (5 percent) = Estimated 8,000 high-risk, high-cost Medicaid beneficiaries. If you are targeting the top 1 percent, full scale would be 1,600 high-risk, high-cost Medicaid beneficiaries.
    • As another example, if your target population is all Medicaid patients with heart disease and depression, your full-scale population is the total number of Medicaid patients with a claims diagnosis for both heart disease and depression.
  • If you have a community-defined population, or defined geographically, use population estimates to calculate full scale.
    • For example, for a target population of frail older adults in your community, identify the size of your community (e.g., 500,000), the proportion of adults ages 65 and older (e.g., 13.1 percent), and the proportion of older adults who are designated as frail (e.g., 5 to 10 percent). Calculate your full-scale population using the following formula: (Total size of community: 500,000) x (proportion age 65 and older: 13.1%) x (proportion designated as frail: 5% to 10%) = Estimated 3,275 to 6,550 frail older adults.
  • Work with senior leaders to establish a realistic timeline to reach full scale. Organizations working with populations with complex needs and high health care costs have cautioned against moving too slowly or too quickly toward scale. Strike the balance that works best for your organization.
  • Track the percentage of your full-scale population that has been served by the enhanced care program, including those currently in the program and those who have graduated from the program. Share this data with your improvement team on a monthly basis, and with key stakeholders at a frequency that aligns with your broader communication strategy.
Address structural issues that require expansion to match increasing scale.

A scale-up-grid can help your improvement team proactively think about what will be needed to grow your program. Review examples of scale-up grids from IHI Better Health and Lower Costs for Patients with Complex Needs Collaborative participants. 

  • Identify structural issues that require expansion to match increasing scale. Use the 5x approach to predict or define the structural issues that you anticipate, and to chart a path forward for testing the expansion of different elements of your program. Consider strategies and requirements for components described in this Care Redesign Guide:
  • Think about each of the above-mentioned components individually. Consider which aspects of the care model work well with five patients that probably won’t work with 25, 125, or more patients. Consider the following structural issues for each component:
    • Human resources (i.e., workforce organization, capabilities, capacity, and oversight)
    • Physical resources (e.g., space, equipment, capacity)
    • Information technology
  • Consider the structural issues for your program as a whole:
    • Learning system (e.g., including data collection, data management, and use of data for improvement)
    • Financial strategy for supporting your enhanced care model and financial rationale for continued investment (e.g., business case)
    • Oversight (e.g., who will oversee the management of the program and its improvement)
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.

A sustainable enhanced care model model is designed to reliably produce key outcomes in patient health, experience, and cost.

Cultivate ongoing investments to enable a sustainable enhanced care model for your population with complex needs and high health care costs.

Identify the four key audiences that will support your program:

  1. The organization that pays for health care delivery
    • This audience includes the payer or health plan that is accountable for health care costs, and may be accountable for health outcomes, patient experience, and provider satisfaction. Be ready to share information on high-level population metrics, including total costs of care, emergency room utilization, and hospital utilization.
  2. The organization from which you derive resources
    • This audience includes senior leaders of your organization, such as the Chief Executive Officer, Chief Medical Officer, and Chief Financial Officer. It may also include your organization’s Board of Directors or Board of Trustees. Understand which population and outcomes they are accountable for; which incentives support or hinder the success of enhanced care programs; and what competing priorities may exist. This audience is often focused on cost issues, health outcomes, patient experience, and provider satisfaction. Build a base of shared understanding and support among these organizational leaders that enables your program to survive through changes in leadership. Develop a relationship with an executive-level champion that can support your implementation team in navigating the fiscal, political, social, and medical barriers that may occur over time.
  3. The medical community from which you need referrals
    • This audience includes the physicians and other care providers within the medical community who will refer individuals to your enhanced care model.  Develop and share a value statement that explains the expected benefits and limitations of your enhanced care model (e.g., a statement of “What’s in it for me?”). Include how your care model may minimize existing pain points in the system (from the perspective of the medical community). Be honest and transparent, and don’t overpromise what you hope to deliver. Anticipate that providers will be concerned about the financial and relationship implications of working with your enhanced care model, and may feel in competition for the same set of patients.
  4. The patients you seek to enroll.
    • This audience includes the people in your population with complex needs and high health care costs and their families or other members of their informal care network. Members of this audience are often interested in how your enhanced care model will be different than their existing care model, and how it will help ease the burden of their current life situation. Work with your patients over time to understand their assets and needs and how to address what matters most to them. Create value by demonstrating that your staff care about them as a person, and that the enhanced care model can begin to address their needs in a way that hasn’t been done before. Stanford Coordinated Care, an ambulatory ICU, used a human-centered design process to deeply understand what potential patients wanted that was different. Review this resource for an example of their process and results.
Meet with your four key audiences to learn what matters most to them and to create shared expectations around value.
  • It takes sustained effort to develop support and interest among your four audiences. Meet with payers, leaders, providers, and patients to understand how the enhanced care program aligns with the priorities of each audience. Learn what matters most to them, how they measure and define success, and how they want to be kept informed of the work with the enhanced care model.
  • Take the following actions:
    • Identify who on the enhanced care team has responsibility for developing and maintaining relationships with payers, organizational leaders, providers and other staff, and patients and families.
    • Conduct a stakeholder analysis to understand the assets and needs of your audiences, what is important to each audience, and how your enhanced care program can support each audience.
    • Customize the delivery of your message to align with the needs of your audiences. For example, some audiences may want regular reports (such as a monthly report on enrollment and health outcomes), some may want data and patient stories, and others may want to discuss progress at regular meetings.
    • Understanding what stakeholders want as their “return on investment” is the key to developing a strong value statement- whether it be financial, improved patient health outcomes or provider satisfaction.


“Within my hospital, the Chief Financial Officer is one of my peers on the executive team, so I make sure I keep him up-to-date on what we’re doing in our enhanced care model. I share a monthly PowerPoint on current status and then ask him if he has any questions. We’ve also had a lot of internal conversations about community benefit and IRS requirements for our hospital and how the enhanced care program aligns with those things. For sustaining the program at a small scale, that’s fine. As we scale up, we will explore ways to implement a sustainable strategy that can help our enhanced care model reach even more people.”Shelly Johnson, RN, MPH, MBA, FACHE, Chief Operating Officer, Spectrum Health Gerber Memorial
Develop the value statement for your enhanced care model and identify different ways of calculating return on investment (ROI).
  • Create a value statement that lays out the rationale for your enhanced care model and for continued investment across the four audiences. When possible, frame your value statement to align with the interests and needs of the four audiences. The examples in the table below show how an organization might frame the value of their enhanced care model.
  • Be creative in understanding various ways of calculating ROI. Develop scenarios that show ROI resulting from improvement in different domains. Consider financial and other non-financial types of return on investment.
Domain  Return on Investment Rationale / Description Example    
Addressing health care needs that have been unmet in the past Patient activation, health status, and health confidence are important predictors of engagement in care, better health outcomes, and cost. Patient satisfaction may result in greater engagement and better self-management. Improving these elements can be a stepping stone to achieving other forms of ROI. Seek permission from patients and their families to work with them to develop brief stories or videos of how the enhanced care program has helped them better self-manage their health. Highlight how your enhanced care model differs from traditional care models, and how your program can build the confidence of individuals to manage their own health. CareOregon, a Medicaid health plan, created this video as a way to message the deep value of their program.
Increasing morale and joy in work Staff satisfaction and joy may result in lower turnover and fewer providers leaving your networks. Use periodic surveys to assess staff satisfaction and include testimonials from staff about their experiences with the enhanced care program. Assess whether provider and staff turnover decreases as work satisfaction increases.
Creating efficiency or reducing costs: Parent Organization Calculate the cost of your intervention and compare that to avoided costs (potential or observed decreases in utilization). When calculating the cost of your intervention, include indirect costs such as clinical supervision, mobile technology, driving costs/time, program oversight, evaluation, and other services. Aim for medical delivery to be self-supported by billings. This type of ROI can impact shared savings arrangements and pay-for-performance initiatives. Highlight the impact of decreasing the number of missed primary care appointments. Decreased ambulatory-sensitive admissions create efficiency in the emergency department and inpatient care. Calculate how the cost of the enhanced care program compares to the potential or actual avoided or saved costs. When developing ROI, some organizations determine the average cost of an ED and/or inpatient visit for their chosen population and tally how many ED and hospital visits would need to be avoided to pay for their intervention.
Creating efficiency or reducing costs: Partnering organizations Calculate the financial savings to other health and social service sectors that can be attributed to your enhanced care model. Look for decreased use of services, such as emergency care, hospitalization, and law enforcement / medical transport services. One organization calculated decreases in police activity after patients engage in care. Another funded a multipurpose community center with initial funds from the Sheriff’s Department after identifying that police costs associated with deputy sheriffs accompanying patients to the ED resulted in an average cost of $4 million per year.
  • Use multiple arguments as part of your value statement. Other areas to consider include patient satisfaction, delivery of evidence-based care, and alignment with the moral values of your organization.
  • Develop a shared understanding of a realistic estimated timeline to achieve return on investment.
  • Use process and outcomes data and patient stories or case examples to support these messages and use them to keep your four audiences engaged over time. Distill the story of your work into crucial highlights to garner ongoing support from diverse audiences. Consider the following questions:
    • What is your population and what are their assets and needs?
    • What services do you offer for this population?
    • What care model have you designed to deliver those services?
    • Who is on the care team and what are their roles?
    • How do you identify patients?
    • How do you engage patients in care?
    • What are the benefits to the patient?
    • What are the patient stories that guide your care design?
    • What standard work processes have you developed to ensure consistent care delivery? 
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.