VBC best practices: Tailoring care for patients with data

Chicago-based Oak Street Health is a pioneer in implementing value-based care with its focus on improving the health and wellness of older adults.

The group practice offers a wide range of services to its patients, and it prides itself on seeing fewer patients so that physicians are able to spend more time with patients, enabling clinicians to understand individual circumstances and develop comprehensive care plans. It also serves patients by offering minimal wait times, door-to-door transportation and “a community of peers and activities to stay busy.”

At Health Data Management's inaugural Best Practices in Value-Based Care (September 21 and 22 in Dallas) Terry Olson, MD, senior vice president of accountable care at Oak Street, will offer a case study describing the organization’s mission, strategy and tactics on its journey to value-based care.

Oak Street Health’s primary focus is adults with Medicare. Why this population?
At Oak Street, we focus on older adults for three specific reasons. First, no one else seems to do it very well. Second, it allows us to clinically focus. Third, as a value-based practice, we invest in primary care with the goal of reducing hospitalizations and using those savings to fund our care model.

Could we do good prenatal care? Sure. But because we don't have to, we can focus very specifically on the things that matter to older adults, things like structured geriatrics assessments, geriatric-friends facilities and the like.

Older adults go to the hospital somewhat frequently, so that means our investments in primary care yield savings pretty quickly. Compare this to kids: if society stopped immunizing kids tomorrow, it would take 15 years for mumps to become a problem. For older adults, however, it only takes Oak Street a few weeks to measure meaningful improvements in our patients' health.

What are the biggest challenges the organization will face this year?
Challenges today at Oak Street are really no different than they were last year or the year before. We're bringing a new model of care to our patients and our teams, and that means we're really in the business of behavior change.

Teaching physicians to practice population health, teaching teams to practice team-based medicine, teaching patients to take advantage of expansive primary care services... The day-to-day approach evolves, but the challenges are the same.

What technology tools or platforms are mission critical at Oak Street?
First, you're never done with technology, tools or platforms. We started from scratch, and now we have what we think is a pretty sophisticated model of data capture and reporting to inform decisions at the point of care.

We've not found a single vendor that covers all the various things that we need, and we never will. We've built our practice precisely for this type of primary care-led value-based care, so that means we create unique needs and thus also need to create the tools to solve those needs.

We have built a home-grown enterprise data warehouse that pulls data from a multitude of internal and external data sources. This warehouse, then, is what we use to build reporting and feedback capabilities for our teams. Everyone wants to talk about technology, but one of our mission critical platforms is the time, space and culture for care teams to huddle.