Care Delivery Innovation Reference Guide

Benchmark your interventions for a successful population health strategy

Jump to specific interventions

Select one of the four options below to view specific interventions associated with that risk level. Each risk-specific intervention will populate with a brief description and a link to download the reference guide. The reference guide will outline the strength of evidence behind the intervention, a summary of the demonstrated impact, and best practice resources.

Patient risk level

High risk
3-5% of total patient population with 3+ chronic conditions; drives majority of health system spending
Rising risk
20-30% of total patient population with 1-2 chronic conditions; 20% elevate to high-risk every year
Low risk
70% of total patient population with 0-1 well-managed chronic conditions
System wide
Entire patient population benefits from system-wide wellness initiatives

High risk:

Behavorial health

  • Medication-assisted treatment (MAT) combines medications (e.g., methadone, buprenorphine) with behavioral therapies to treat substance use disorders, primarily opioid use disorder and alcohol use disorder. Download reference guide.
  • Care coordination/management

  • Care transition support includes services that help ensure patient care is maintained when the patient moves from one site of care to another. Usually, care transition programs focus on ensuring continuity of care when a patient is discharged from the hospital either to home or to another care site. Download reference guide.
  • Community paramedicine programs are partnerships between acute care providers and local EMS providers to deploy advanced practice paramedics who provide patient-centered in-home health care services to underserved populations. Download reference guide.
  • Emergency department-based navigation designates ED staff (e.g., nurse, social worker) to educate frequent ED users, enhance care coordination, and ensure safe transitions. Download reference guide.
  • High-risk care management is an intensive, team-based care management approach focused on cross-continuum coordination and comprehensive care planning for high-risk patients. Download reference guide.
  • Medication therapy management encompasses a range of services (e.g., medication reconciliation) provided by pharmacists to help manage complex pharmaceutical regimens. Download reference guide.
  • Disease management

  • CHF chronic disease management support aims to help patients manage their chronic heart failure in the long-term. Programs take different forms, but are usually based in an outpatient setting and often employ remote monitoring or other telemedicine services. Download reference guide.
  • Chronic depression management support aims to help patients manage their depression in the long-term. Programs take different forms but are usually based in an outpatient setting and include regular patient contact and some type of psychotherapy and medication adherence promotion. Download reference guide.
  • Chronic disease management support refers to programs that aim to help patients manage their chronic diseases in the long-term. Programs are usually based in an outpatient setting. Download reference guide.
  • COPD chronic disease management support includes education about the disease, optimization of evidence-based medications, and training patients to self-manage. Download reference guide.
  • Diabetes chronic disease management support refers to programs that aim to help patients manage their diabetes in the long-term. Programs take different forms, but are usually based in the outpatient space and often incorporate an aspect of peer support through mentoring or group medical visits. Download reference guide.
  • Hypertension disease management programs aim to help adult patients with blood pressure readings at or above 130/80 mmHg to lower and maintain lowered blood pressure. Download reference guide.
  • Peer mentoring is a non-clinical support mechanism through which patients receive health education and/or coaching from someone with similar life experiences. Peer mentoring is often used in chronic disease management and behavioral health. Download reference guide.
  • Patient engagement

  • In-person health coaching is when a care team member (e.g., medical assistant) guides and supports patients through behavior change by focusing on internal motivation and personal goal setting. These programs often target individuals with asthma, heart disease, diabetes, and chronic pain. Download reference guide.
  • Primary care innovation

  • Patient centered medical home (PCMH) is a primary care delivery model that emphasizes care coordination, enhanced access, and patient engagement by using team-based care and standardized workflows. Download reference guide.
  • Super-utilizer clinics are dedicated to managing care of emergency department and inpatient super-utilizers and connecting patients to primary care. Download reference guide.
  • Serious illness care

  • Advance care planning is the process of assisting patients to determine details of the end-of-life care they would like to receive if they are unable to advocate for themselves. Download reference guide.
  • Family/caregiver support programs aim to relieve the emotional and psychological burden families and caregivers of patients with serious illnesses experience. Download reference guide.
  • Hospice care is a type and philosophy of end-of-life care, which includes non-curative medical care, pain management, and counseling services, for patients facing a terminal illness. Download reference guide.
  • Palliative care is a type of medical care provided to patients with serious illnesses to relieve pain and symptoms. Palliative care can be provided simultaneously with curative treatment across all settings. Download reference guide.
  • Social determinants of health

  • Community health workers are trained and trusted members of the community who serve as a bridge between health care providers, community-based organizations, and patients. They generally perform health education, chronic disease management, community advocacy, navigation in community settings, and outreach and enrollment. Download reference guide.
  • Employment/income support includes a range of interventions that support the financial security of low-income or unemployed patients (e.g., income supplements, career and financial coaching, job connection, job training, and safety-net benefit connection). Download reference guide.
  • Food security services include a range of approaches to improve access to healthy and affordable food for patients and communities (e.g., food pharmacies, SNAP¹ enrollment assistance, nutrition/cooking classes). Download reference guide.
  • Mobile health clinics provide health care services on a mobile van for vulnerable populations by reducing traditional barriers to access (e.g., transportation, time constraints, distrust of health care system). Download reference guide.
  • Supportive housing programs subsidize or offer free places for patients to live temporarily or permanently, through a provider/community organization partnership. Download reference guide.
  • Telehealth

  • Remote monitoring is the use of technology to enable providers to monitor patient clinical indicators outside of care settings. Download reference guide.

Rising risk:

    Behavioral health

  • Medication-assisted treatment (MAT) combines medications (e.g., methadone, buprenorphine) with behavioral therapies to treat substance use disorders, primarily opioid use disorder and alcohol use disorder. Download reference guide.
  • Care coordination/management

  • Care transition support includes services that help ensure patient care is maintained when the patient moves from one site of care to another. Usually, care transition programs focus on ensuring continuity of care when a patient is discharged from the hospital either to home or to another care site. Download reference guide.
  • Disease management

  • CHF chronic disease management support aims to help patients manage their chronic heart failure in the long-term. Programs take different forms, but are usually based in an outpatient setting and often employ remote monitoring or other telemedicine services. Download reference guide.
  • Chronic depression management support aims to help patients manage their depression in the long-term. Programs take different forms but are usually based in an outpatient setting and include regular patient contact and some type of psychotherapy and medication adherence promotion. Download reference guide.
  • Chronic disease management support refers to programs that aim to help patients manage their chronic diseases in the long-term. Programs are usually based in an outpatient setting. Download reference guide.
  • COPD chronic disease management support includes education about the disease, optimization of evidence-based medications, and training patients to self-manage. Download reference guide.
  • Diabetes chronic disease management support refers to programs that aim to help patients manage their diabetes in the long-term. Programs take different forms, but are usually based in the outpatient space and often incorporate an aspect of peer support through mentoring or group medical visits. Download reference guide.
  • Hypertension disease management programs aim to help adult patients with blood pressure readings at or above 130/80 mmHg to lower and maintain lowered blood pressure. Download reference guide.
  • Peer mentoring is a non-clinical support mechanism through which patients receive health education and/or coaching from someone with similar life experiences. Peer mentoring is often used in chronic disease management and behavioral health. Download reference guide.
  • Telephonic self-management support programs provide support and advice to patients using goal setting and motivational interviewing tactics. Download reference guide.
  • Patient engagement

  • In-person health coaching is when a care team member (e.g., medical assistant) guides and supports patients through behavior change by focusing on internal motivation and personal goal setting. These programs often target individuals with asthma, heart disease, diabetes, and chronic pain. Download reference guide.
  • Primary care innovation

  • Group medical visits/shared medical appointments are most commonly used for patients dealing with a chronic illness such as diabetes. Appointments often include designated one-on-one time for each patient to see the physician, as well as group education time. Download reference guide.
  • Patient centered medical home (PCMH) is a primary care delivery model that emphasizes care coordination, enhanced access, and patient engagement by using team-based care and standardized workflows. Download reference guide.
  • Social determinants of health

  • Community health workers are trained and trusted members of the community who serve as a bridge between health care providers, community-based organizations, and patients. They generally perform health education, chronic disease management, community advocacy, navigation in community settings, and outreach and enrollment. Download reference guide.
  • Mobile health clinics provide health care services on a mobile van for vulnerable populations by reducing traditional barriers to access (e.g., transportation, time constraints, distrust of health care system). Download reference guide.
  • Social cohesion interventions include a range of services aimed at reducing patient loneliness and building social connections, including improving social skills, enhancing existing social support, and increasing opportunities for new social contact. Download reference guide.
  • Wellness

  • Weight management programs are lifestyle interventions (e.g., diet, physical activity, behavior change support) with the goal of helping obese or overweight patients achieve and maintain a healthy weight and minimize risk factors or symptoms of chronic disease. Download reference guide.

Low risk:

    Social determinants of health

  • Social cohesion interventions include a range of services aimed at reducing patient loneliness and building social connections, including improving social skills, enhancing existing social support, and increasing opportunities for new social contact. Download reference guide.
  • Telehealth

  • Virtual primary/urgent care allows patients to access primary care or urgent care services through a web-based platform instead of meeting with a physician in person. Download reference guide.

System-Wide

    Behavioral health

  • Integrated behavioral health is a team-based model that incorporates behavioral health services into primary care. Collaborative care teams intervene for low-to-moderate acuity needs and coordinate intensive care for moderate-to-high acuity needs. Download reference guide.
  • Universal depression screening involves the screening of all patients in the primary care setting, using standardized measures like the PHQ. Download reference guide.
  • Care coordination/management

  • Nurse triage lines are a telephonic service that assists patients in assessing symptoms and determining the appropriate site of care. Download reference guide.
  • Preferred post-acute networks are groups of post-acute care (PAC) providers (usually skilled nursing facilities) selected by a hospital or health system to collaborate and streamline post-discharge care. Download reference guide.
  • Disease management

  • Asthma disease management programs deploy clinical and non-clinical staff to work with patients to create action plans, provide disease and medication education, and support self-management skills training. Download reference guide.
  • Patient engagement

  • Health literacy support includes a range of educational interventions aimed at improving patients’ understanding of their diagnoses and care plans. Download reference guide.
  • Motivational interviewing is a patient-centered, collaborative communication style intended to strengthen a patient’s motivation and commitment to behavior change. Download reference guide.
  • Patient education is the part of treatment when patients are informed about their health status and care plan in a culturally competent manner. Education often includes tactics such as teach-back or pictorial educational materials. Download reference guide.
  • Shared decision making is a collaborative communication technique used to ensure the values and preferences of patients and their caregivers are sufficiently incorporated into the care plan. Download reference guide.
  • Teach back is a communication method used to confirm patients’ understanding of care plan and self-management instructions by having patients repeat key information back to staff in their own words. Download reference guide.
  • Social determinants of health

  • Language-concordant care includes services (e.g., live interpretation support, bilingual physicians) that support effective communication with patients with limited English proficiency (LEP) and/or deafness. Download reference guide.
  • Non-emergency transportation services includes the provider-led service of coordinating or offering transportation to and from medical appointments. There are different types of transportation services, including the use of ride-sharing applications, community transportation providers, and taxi vouchers. Download reference guide.
  • Telehealth

  • Self-management mobile applications are interactive digital health tools for patients’ phones and tablets that aim to promote skills to manage disease symptoms. Download reference guide.
  • Wellness

  • Smoking cessation interventions include a range of strategies (behavioral, pharmacological, and psychosocial) to help patients quit smoking. Download reference guide.

Don’t see an intervention you've implemented, but still want to determine financial ROI based on your specific program setup? Use our Population Health ROI Estimator to plug in your numbers and estimate PMPM savings over time.

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