Nailing the fundamentals of value-based care

It was the summer of 1961, and Vince Lombardi was set to coach the Green Bay Packers. In front of him at summer camp was a group of professional football players that had arrived for training camp. In a biography, “When Pride Still Mattered: A Life of Vince Lombardi,” the author explained Lombardi’s approach to building the team that would go on to win the NFL championship just 6 months later.

“He took nothing for granted. He began a tradition of starting from scratch, assuming that the players were blank slates who carried over no knowledge from the year before… He began with the most elemental statement of all. “Gentlemen,” he said, holding a pigskin in his right hand, “this is a football.”

Lombardi knew what others tend to pass over: practicing the fundamentals is always essential—especially when you’re a pro. The same can be said for healthcare teams looking to achieve great things with value-based care. You need to make sure your team of providers, nurses, care managers, front office staff, and others are consistently reinforcing the basics, no matter how much experience they have or how long they’ve been at the organization.

So, what are the basics for value-based care? Let’s get into it.

1. Ace the annual wellness visit: At its most basic, the delivery of value-based care starts with an annual wellness visit. This visit must be marked by easy scheduling, reliable communication, and pristine front office service. This may be the one touchpoint your team gets with a patient and the primary opportunity to build rapport, establish trust, and gather critical medical and social health information.
2. Push relentlessly to improve care access: Any strong population health strategy considers how, when and why a consumer could or does obtain healthcare services. Work hard to ensure access is available to consumers through same day appointments, reliable telehealth options, transportation services, pop-up clinics, and anything else that will serve your particular community well.  
3. Use good data: I’m no math prodigy, but I know this equation to be infallibly true: Bad data in = worse data out. Before you can dive into analytics with abandon, you have to address data inconsistencies and inaccuracies across your entire organization. Far too often I have seen teams work to implement an initiative only to find out the data they “thought” would help inform was not in great shape.
4. Reach out to your patients: I used to think this sounded simple, but 20+ years in nursing proved me wrong. Far too often, proactive communication with patients is missed or dismissed as a nice-to-have, not a fundamental. Work to have a regular cadence of outreach using multiple channels and checkpoints. This is especially critical for communities with a large percentage of high-risk individuals.
5. Always follow up: Build mechanisms to follow up during major care transitions. This is a fundamental that needs to be honed to know the right consumer to call at the right time, and it needs to be practiced every day! Make sure your team is following up post-ED visit or post-hospitalization, particularly for patients who are at a high risk for complications and adverse outcomes.
6. Understand risk profiles: It’s critical to know the risk profile of each patient under your care. With this knowledge, you can more thoughtfully position resources, address critical needs, and keep track of key factors that are impacting your patients’ health journeys. Know the risk, track it, and build processes around it.

If you read this far, it is time to take another step. Sit down with your team and discuss how you’re implementing these fundamentals daily and where there is progress to be made.  Adjust where you need to adjust, persevere with patience, and—just like Lombardi’s Packers—you can become a championship winning team!