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Hospitals and health care systems across the United States are transforming care delivery to better meet the needs of their patients and communities across their lifespans while bolstering long-term financial sustainability.

Achieving this care delivery transformation requires collaboration and goal alignment across all components of the health care system. By leveraging existing tools, hospitals can integrate new technologies, team members and strategies to design and implement care delivery models that enhance the health care experience for both patients and providers.

Through the Care Delivery Transformation Framework, the ºÚÁÏÕýÄÜÁ¿ Association is supporting hospitals and health systems as they explore strategies to improve care for patients and communities. The framework provides a visual representation of how the components of the health care ecosystem facilitate the development and implementation of innovative care delivery models. As hospitals plan and execute new care delivery strategies for the future, the framework and associated resources can help them strategically align those initiatives with the other components of their health care system.

Care Delivery Transformation Framework

The care delivery models in this framework are based on the foundational principles guiding hospitals’ missions and operational infrastructure that enables hospitals to function. These care delivery models have the potential to transform care and are already being implemented by many hospitals and health care systems. They encompass strategies in the clinical and community settings, as well as those that bridge the realms of clinical and community. Integrating these components creates the conditions for health care organizations to transform their care delivery and thrive now and in the future.

Below is a description of each component of the Health Care Transformation Framework.

CARE DELIVERY STRATEGIES

Hospitals are designing care to meet people where they are, whether that is in the hospital, back home in their community, or during the transition in between. Having care delivery models that encompass the hospital-tocommunity continuum is crucial for the future of care.

CLINICAL SETTINGS

• Team-based Care. Developing a culture and structure for interdisciplinary team-based care allows health care organizations to meet the physical, mental and social needs of their patients, especially for those with complex care needs. Creating a structure where each clinician can work to the top of their license will enable better clinical care for patients and greater professional satisfaction.
• Technology-enabled Care. Technological advances can be applied to care delivery to improve patient care and ensure that people are getting the right care at the right time, ultimately improving outcomes.
• Social Needs Screening and Referral. Screening for and addressing patients’ health-related social needs is an important step for providing holistic care.
• Integrated Behavioral Health. Integrating behavioral health professionals into the care team contributes to more holistic patient care.

COMMUNITY SETTINGS

• Community-based Partnerships. Hospitals are adopting strategies to address social drivers of health at the community level, such as inadequate housing or food deserts that impact segments of the populations they serve. While health care alone cannot change community circumstances, hospital partnerships with community stakeholders and other sectors can influence community ecosystems to foster an environment in which all community members can thrive.
• Alternate Care Sites. Innovative health care organizations are designing services to meet people where they are – in community settings such as the home, community-based clinics, schools and retail clinics. This encompasses post-acute, specialty, ambulatory and primary care.
• Telehealth. Virtual services expand access to care so that people can conveniently receive medical advice and treatment wherever they are.

LINKING CARE TO COMMUNITY

• Patient and Community Engagement. Through formal and informal processes, such as community health needs assessments, patient and family advisory councils, community-based programs, hospitals receive guidance on how they can better connect with individuals of all backgrounds.
• Primary Care Transformation. Health systems are transforming primary care to provide care that closes care gaps while prioritizing prevention and managing complex health and social needs across the continuum of care in alignment with new payment models.
• Provider Partnerships. By fostering partnerships across providers as part of a clinically integrated network, health care organizations can better facilitate coordinated care for their patients.
• Care Navigation. Care navigators can help facilitate transitions as patients – particularly those with chronic or complex diseases – move from acute care to home setting while remaining connected to needed outpatient services.

OPERATIONAL INFRASTRUCTURE

There are key, common infrastructure components that support care delivery strategies. Underlying all these operational components, health care organizations have policies and procedures in place to advance their mission, with an eye toward the future as they decide where to devote their financial and staff resources.

• Data and Analytics. Health care organizations have mechanisms to continue to collect, organize and use data from various internal and external sources to guide their care delivery approaches.
• Resilience. Hospitals are creating systems to respond and adapt to changing conditions in the field.
• Workforce. By fostering a strong organizational culture and building interdisciplinary care teams, hospitals can enable their team members to meet their mission and prevent burnout.
• Payment Models. Committing to care delivery transformation alongside the transition to value-based payment enables health care organizations to thrive in the current model and in the future.
• Leadership and Governance. Health care leaders engage their workforce and governing boards to move toward their shared vision and mission together.

FOUNDATIONAL PRINCIPLES

Hospitals and health systems are developing care delivery strategies aligned with core foundational principles that guide their efforts. These principles should intentionally be integrated into the design of care delivery models:

• Person-centered. Every person’s circumstance is unique, and the care they receive reflects that. Health care is designed around the needs and assets of each patient, including their medical, behavioral and social needs.
• Safe and High Quality. Health care organizations constantly reinforce a culture of quality and safety to ensure the well-being of their patients and employees
• Accessible and Affordable. Hospitals are working to make care more affordable and are enabling patients to access care where and when they need it.
• Coordinated. Partnerships across health care professions, industries and sectors allow hospitals to foster an environment that is conducive to improving health. Community stakeholders and patients are key partners in codesigning new care delivery models.