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Although the integration of patient-centered medical homes and accountable care organizations into the health system is still emerging—as are best practices and key learnings from these early efforts—there have been myriad examples demonstrating encouraging returns and improvement in quality of care. The Patient-Centered Primary Care Collaborative recently profiled several organizations that have adopted patient health management (PHM) tools and strategies to address the preventive and chronic care needs of their patient populations.

1. Bon Secours Virginia Medical Group

2. Richmond, VA

3. Provider Type: Multispecialty group practice

4. Locations: 140

5. Patients: 25,000 (Virginia)

A pioneer in implementing medical home and accountable care initiatives, Bon Secours has dedicated itself to executing a sustainable care delivery model that is in alignment with health care reform across its providers and locations. Bon Secours's transformation into an organization that embraces PHM is the result of a systematic strategy to reengineer primary care practices, integrate new technologies into care team workflows, and engage patients in their care.

Bon Secours took a leap of faith in implementing these changes, acting on the belief that payers would come to them if they built a viable model. And payers did. The organization was selected as an early participant in the Medicare Shared Savings Program. It has also signed value-based contracts with two commercial payers—CIGNA and Anthem—and is in negotiations with several more. These contracts provide a financial mechanism to expand and scale the medical home initiative and support ACO models. This case study examines in more detail Bon Secours's approach to position itself to achieve quality outcomes and financial success in the changing health care environment.

Bon Secours's Care Team Model

The foundation of Bon Secours's strategy for value-based care is its medical home initiative—the Advanced Medical Home Project. The project began as a pilot five years ago. Since that time, eleven practices have earned NCQA recognition as patient-centered medical homes. One of the most significant objectives of the Advanced Medical Home Project is to improve capacity—making it possible for care teams to double the size of their patient panel without overburdening themselves or sacrificing quality of care.

At the heart of this medical home strategy is the effort to reengineer practices by creating high-performance physician-led care teams, which requires changes in workflow, new care coordination activities, and designed delegation of clinical responsibilities across the care team. To facilitate this process, Bon Secours has invested significantly in embedding care managers into the primary care team. These nurse navigators are registered nurses (RNs) who are either board-certified case managers or actively working toward certification.