Value-based care (VBC) holds the opportunity to re-create partnerships designed to increase health care sustainability by strategically improving processes, care delivery, and patient outcomes. However, the potential of the Institute of Healthcare Improvement (IHI) Triple Aim framework will never be optimized until the major stakeholders are identified, connected by a common goal, and willing to participate equally. Thus, the movement toward VBC delivery models is found mainly in a balanced partnership of four key stakeholders: patients, providers, payers, and community, together creating the axis of the Value-Based Compass and the road map through which the Triple Aim can be achieved.

This article emphasizes the importance of community as the foundation for advancing value-based care and its engagement with the other primary stakeholders.

Community grounded

Communities have historically not been well connected within contemporary models of health care; however, communities are the root influencer of social determinants of health (SDoH), the non-medical health care drivers that predominantly determine a patient’s health and well-being. A greater status of positive SDOH indicators is a key-stone determinant of the ability to achieve value-based outcomes within a given community. Communities shape and define the health of patient populations through the influence of social norms and health behaviors. Community resources exist to support populations in health and improve patient outcomes, but barriers exist in patients, providers, and payers’ knowledge and access to these resources. When a consistent connection does not exist between patients, health care providers, and communities, navigating the complex health care system may become burdensome and deter patients from appropriately engaging in their health.

By utilizing the Value-Based Compass and anchoring the community as the main stakeholder, the Value-Based Compass framework drives greater impact between community partners and providers to meet the mission and decrease costs based on the highest health needs within the population. Under this approach, the strengths of each stakeholder are leveraged, and gaps in care are closed. Mutual benefit is further enhanced via meeting a shared goal of improving health at decreased cost and providing support and growth of the community from social, economic, and cultural standpoints.

Provider partnered

The provider axis of value-based care traditionally identifies physicians as the primary provider stakeholder. However, successful VBC delivery does not occur in isolation of clinical performance by a single profession. Recognizing the patients’ interaction to broad influencers of quality and cost decisions, the provider stakeholder needs to be expanded to represent the collective professional inputs of health care service delivery, including professions such as nursing, physical and occupational therapy, pharmacy, social work, and health care administration.

Continuous quality improvement must be cultivated within health systems on the premise of integrated team-based care management. Leveraging Lean design principles, efficient and efficacious clinical workflows can be constructed then followed by the PDSA quality improvement method to hone and hard-wire the process. One example of quality improvement work towards VBC goals is in developing longitudinal care pathways aligned to a patient’s anticipated clinical journey, including pathway integration of transitions in care services. Starting in the ambulatory care space for chronic disease states, clinical pathways direct patient care towards comprehensive care management. Incorporation of community-based resource referrals within the pathway may be included to address SDOH care gaps and facilitate integration with holistic care delivery. Advanced care pathways may also be developed that extend from ambulatory care into acute care services with integration of the pathway back into the ambulatory (primary care) setting to reduce gaps in care that historically occur during care transitions.

Payer supported

The collaboration between payers, providers, and communities must be guided by a movement away from a fragmented model premised on episodic intervention to one based on coordinated care built around the site of care and patient acuity. One must remember that 80% of a member’s health is influenced outside the four walls of traditional health care settings. Thus, a key element of transitioning to more value-based care models involves considering community engagement when adjusting for reimbursement rates. Payers must partner closely with hospitals and local organizations to share gaps in care information and important SDoH data to assist providers in managing the care of their patients, as well as paying for services that extend coverage to an ecosystem of coordinated care within the community – including mental health services and low-income assistance programs.

Payers can further support the idea of communities being the foundation for value-based care programs by encouraging providers to grant local organizations access to their EMR data. While there will need to be a discussion between stakeholders around what is considered minimal and necessary, data sharing will enable informed decision-making and better coordination of care between stakeholders, effectively capturing a holistic picture of a population’s health outcomes and of community programs’ impact on improving the quality of care outside the hospital.

Patient-centered

Previously noted, the majority of a person’s health is highly reflective of one’s community social and behavioral norms. The community serves as an influencer and support system for patients’ health and wellness behaviors, including consumer access to health-related resources. With the goal of empowering patients as informed health consumers, community engagement can aid patients in education around accessing, navigating, and paying for care within a complex system.

Together with payers and providers, the community can strengthen available outreach through the integration of health and community literacy, creating pathways for communication, health promotion, and improved patient access to care. One example of literacy integration is in communities with greater hypertension risk within the population. Education through community literacy may focus on awareness of hypertension risk factors, knowledge around blood pressure monitoring and common behavioral and medical management recommendations used for disease control, and demonstration of when to seek treatment for elevated blood pressure.

Patient choices drive a significant portion of patient outcomes. Building health literacy through the community impacts the ability for community populations to actively engage in health-promoting choices, adhere to care recommendations, and avoid costly consequences of reactive health care engagement.

Grounded in community, positioned for North Star care

The status quo of conventional health care delivery is unsustainable by cost and outcome standards. As a roadmap, the Value-Based Compass can be utilized as a framework to improve quality outcomes and link each stakeholder’s priorities. More importantly, the community is an integral influencer of both upstream and downstream in VBC delivery. By anchoring the community as the focal point within the Value-Based Compass, providers and payers can successfully improve the health of populations, lower the cost of care, and create an encompassing environment that recognizes that health and value are best harnessed where people live, work, and play.

Kristan Langdon is a nurse practitioner. Timothy Lee is a health care strategist.