AMITA Health Places Patient at Center of Care Management Redesign

Susan WickeyIn rolling out a new connected care management strategy across its nine-hospital system, AMITA Health aimed to keep its target patient population at the heart of the initiative—unit by unit, floor by floor. Here, Susan Wickey, vice president, quality and care management at AMITA Health, shares one of the guiding principles of the Medicare Shared Savings Program Accountable Care Organization (MSSP ACO).

The key component for us in our redesign was making sure that the patient was at the center of everything we did. With that in mind, we developed structured processes and programs that would span the care continuum while retaining the patient at the center. We wanted to establish relationship-based care with the patient and the primary care physician. We wanted to be able to use available data to help drive our decisions. We wanted to ensure that our patients had regular access to care, and that we leveraged what we currently had in place.

Our congestive heart failure clinic was key in this process. Navigating through the care continuum is not an easy process for many of our patients. We wanted to make sure we could help them through that, and construct some processes for them to be able to navigate. We wanted to make sure we were continuing to build the health literacy of our patients and our families. We wanted to establish interventions for the most vulnerable population of patients. We wanted to make sure we had a dedicated, multidisciplinary team to help us. We had psychiatrists, dieticians, pharmacists, primary care physicians and physician champions along the way to help us.

We began implementation very slowly, starting with a specific cohort of patients on one specific unit. This cohort was small; the number of people touching the cohort at the time was small. As we went along, we were able to define problem areas where we needed to intervene, quickly readjust and then go down the right path.

Slowly, over a period of time, we were able to add additional floors in our acute care hospitals, which then meant adding additional staff. Those additional staff then became the super users who helped us roll out the program on the next floor.

Excerpted from: Centralized Care Management to Reduce Readmissions and Avoidable ED Visits in High-Risk Populations, which describes how AMITA Health, a nine-hospital system, inventoried, reexamined and revamped its care management resources, ultimately implementing a centralized care management model. For more information, please visit:

In this 25-page resource, AMITA Health's Susan Wickey, vice president, quality and care management, and Luke Hansen, MD, MPH, vice president and chief medical officer, population health, guide readers through their organization's care management redesign, which operates on the premise that AMITA's patients are never really discharged but only are transitioned to the most appropriate care site. To download or order your copy today, please visit:

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