Delivery System Transformation

Health care delivery is evolving. For example, the Patient Centered Medical Home (PCMH) is a rapidly expanding approach which seeks to transform care delivery with a team-based focus on care coordination and overall health management. Health homes strive to better integrate care for those with chronic conditions and those in need of behavioral health services.

These and other types of models emphasize practice transformation and the provision of an improved patient experience with options such as 24/7 access to care, availability of same-day appointments, assistance with self-care, and support from community and social services organizations. Enhanced health information technology capabilities, telemedicine, and critical care training for physician extenders such as nurse practitioners and physician assistants are allowing for new care delivery options, particularly in settings with more fragmented care delivery systems such as underserved and disadvantaged urban communities.

The Delivery System Transformation area focuses on projects related to innovations in care delivery, such as those which might be adopted by organizations participating in PCMH, ACO and other payment reform initiatives and models.

Accomplishments and Collaborations

Ongoing Projects

  • Randomized Evaluation of In-Home Intervention to Manage Acute Changes in Home Care Patients
  • Improving the Value of Health Care Spending
  • Measuring Clinical and Economic Outcomes Associated with Delivery Systems
  • Evaluating the CareFirst Patient-Centered Medical Home

Other Activities

  • Landon presented to both CMMI and the Agency for Healthcare Research and Quality (AHRQ) on his work on primary care workforce simulation.
  • McWilliams is advising MedPAC on measuring low-value care.

Selected Papers and Publications

  • Dean KM, Hatfield LA, Jena AB, Cristman D, Flair M, Kator K, Nudd G, Grabowski DC. Preliminary Data on a Care Coordination Program for Home Care Recipients. Journal of the American Geriatrics Society; forthcoming 2016.