Table 5.

Facilitators of AHR High Performers’ Efforts to Prevent Acute Hospitalizations

Facilitator	Mechanisma	Illustrative Quote
Experience with and investment in practice transformation	Provided practices necessary payment structure, incentives, resources, and capabilities to track AHR Offered learning supports that helped practices use data and adopt new workflows	“CPC+ was the first time we were responsible for total cost of care… that we, as a practice, were financially connected to the hospitalization rate. We weren’t measuring that at the practice level [before CPC+]. Once we had a financial connection and mechanism to track that, we completely changed our workflows.” – PCP
Use of data from CPC+, other payers, health systems, and electronic health record enhancements	Enabled practices to monitor high-risk patients, intervene early in their care, and link them to helpful resources Improved PCPs’ ability to make point-of-care decisions	“All of a sudden, we were given lists that say, ‘These are your 10% of patients who are hospitalized the most or have the most ED follow-up, the most chronic disease.’ By identifying these patients, we were able to link them to our new ancillary services [within the primary care practice site] and really tackle the reasons that they’re not doing well.” – PCP
Implementation or enhancement of primary care teams through team-based care models	Allowed staff to work at the top of their license and cover for each other to prevent gaps in care Strengthened patients’ trust in care team members in addition to PCPs	“I think how cohesively the care team works together makes a big impact. At many of our [non–AHR high-performer] sites, often the care team doesn’t make a move without getting the provider’s permission first. The fact that [we’ll] just dive into what the patient needs right then, and then loop in the provider later is unique.” – PCP
Organizational support for and staff interest in innovation	Gave staff permission to try new approaches and take risks Helped staff implement and hone new workflows and processes Fostered a focus on using data to identify issues and implementing quality improvement projects Enabled system-owned AHR high performers to undertake investments that would be too expensive to make on their own	“We are very open [to our staff] identify[ing] potential problems. Small acts of change, or small plan-do-study cycle–type projects we do at an ongoing, never-ending basis. [This practice has] been very, very supportive of small tests of change consistently, [whether that is] workflow changes [or] IT changes. And because we’re making microchanges consistently, they tend to stick because they’re not huge changes to the workflow redesign.” – Pharmacist

AHR = acute hospitalization rate; CPC+ = Comprehensive Primary Care Plus; ED = emergency department; IT = information technology; PCP = primary care practitioner.

^aMechanism by which the facilitator supported care delivery activities within the 3 overarching strategies.