At Bayhealth, value-based care helps put the patient first

While the complexity of value-based care arrangements can bewilder even the brightest minds in health care, Bayhealth finds that a patient-focused mindset helps to keep things simple.

For physicians and their care teams at Bayhealth, the focus on value-based care has meant helping a woman in an abusive relationship find a way out, helping a patient living in a tent find an apartment and get surgical treatment for his cataracts, and delivering lifesaving treatment for a brain bleed discovered during an annual wellness visit. These are just a few of the memorable cases that stand out, but the broader numbers also make the case for Bayhealth’s approach.

During the last three years, Bayhealth has worked with the eBright Health Accountable Care Organization (ACO) to improve its performance on quality measures and achieve better patient outcomes across several patient populations—from traditional Medicare patients to patients enrolled in managed-care plans. 

In total, Bayhealth’s 12 value-based programs, including the eBright partnership, have served about 21,000 patients in the last three years, and the number has increased steadily year over year.

Here is how Bayhealth manages to align value-based care goals for thousands of patients across payers and programs.

“Our value-based care initiatives are ultimately all focused on quality of care, clinical best practices, patient engagement and experience, and effective cost utilization,” said Lara Hudson, MSN, BSN, RN. She is senior director of population health at Bayhealth, which is a member of the AMA Health System Program that provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.

“We have a strategic plan in place that runs from 2024 to 2026, and we evaluate throughout the two years, each time improving quality and service while reducing cost of care through enhancing efficiency,” Hudson said.

To engage individual Bayhealth staff towards larger value-based quality goals, Hudson and team start by evaluating performance data on measures, then set up a method to not just meet the goals but tangibly improve quality of care.

“We're also advancing a culture of high engagement and high performance to strengthen the health of our community one life at a time,” said Hudson.

This is helped by selecting a few areas to focus on at one time.

“We select at least two quality metrics we focus on for our strategic plan each month,” said Hudson. “We monitor that improvement every quarter and figure out where we are—but in a way that doesn’t overwhelm our staff.”

Learn more with the AMA about seven keys to success with value-based care pay arrangements.

A major cornerstone of Bayhealth’s approach is data is compiled into a dashboard that helps physicians, front office staff and other members of the care management team quickly digest the most pertinent information and track trends. This dashboard is integrated into the EHR system to allow physicians and care teams to nimbly stay aware of their patients’ unique needs and care plans.

“Any physician, supervisor, medical assistant, our population health team and any nurse can go in, see all of those standards, and drill down to the patient,” said Hudson. “They can look at them quarter-over-quarter and work the list to see if any patients are experiencing a quality gap.”

“By utilizing data, we're able to drill down on the most at-risk patients and connect them with nurses and social work support,” said Ashley Istenes, Bayhealth’s senior manager of population health operations. “We use the reports to find higher-risk patients. For example, if someone hasn't been in for an appointment in a long time … we're aware of our population, and we can quickly get our patients in for an appointment and complete their wellness visit.”

Right now, Bayhealth tracks trends related to breast cancer, colorectal cancer, hypertension, A1c for patients with diabetes, following up on hospital discharges, annual wellness visits for Medicare populations, and other chronic conditions, along with preventive screenings.

Between 2021 and 2023, Bayhealth saw a wide range of improvements that were bolstered by their value-based care approach:

• Annual wellness visits went up 8%.
• Follow-ups after hospital discharges rose by 2%.
• Readmissions were down by 3%.
• Screenings for breast cancer, colorectal cancer and hypertension increased by 8%, 4% and 7% respectively.

“Or we can set them up with support services such as our social worker, chronic-care manager or our brand-new behavioral health consultant,” Istenes added, noting that all three are embedded in practices.

Explore this playbook released this year by the AMA and other major stakeholders: “Creating a Sustainable Future for Value-Based Care: A Playbook of Voluntary Best Practices for VBC Payment Arrangements” (PDF).

Bayhealth physicians and care teams have found that using an online patient portal has been central to helping patients participate more in their care.

“We’ve learned not to make assumptions about how the patients will fare with their involvement” with the patient portal, Istenes said. While some may speculate that older adults “wouldn’t use the online portal, we find that patients even in their late 90s have adapted to it well.”

One way the patient portal has been helpful has been reminding patients to schedule their annual wellness visits. Initially, patients did not take much advantage of annual wellness visits when they began several years ago. But in 2023, Bayhealth held about 8,000 Medicare annual wellness visits, an increase compared to previous years.

“Patients now ask me directly when their annual visit will happen because they’re looking forward to it,” said Preeti Gupta, MD, a family and population-health physician at Bayhealth.

Boosting the rate of Medicare annual wellness visits has helped to uncover a range of patient needs that Bayhealth physicians and care team can help to address earlier.

“One patient at a wellness check was embarrassed to share that he fell the night before and had a serious head injury. He was sent to the ER, where they found he had brain bleed,” said Istenes. “Another patient was being abused by her husband and that visit was her first chance to get away from him since the pandemic. And we had a woman who just needed a better understanding of advance care planning at home. That one check-in can reveal a lot of needs.”

These visits also help to foster patient-physician relationships, which in turn reinforces patient engagement, creating a positive loop that extends beyond the annual wellness visit.

“Now they know their nurses by name, and because they feel genuinely cared for, they’re engaged and participating,” said Dr. Gupta. “Patients will now message me to say they’re ready to come in because it’s time for their mammograms and other preventive screenings.”

Gathering useful data through screenings and various check-ins has led to unique solutions to specific health issues, both in regard to physical health and connected social drivers of health.

At Bayhealth, patients 18 or older are routinely screened during initial visits to uncover any health needs they may have outside of facility walls. Among the social drivers of health that are touched on in the screenings is food insecurity. Through a partnership with the Food Bank of Delaware, Bayhealth has been able to provide 1,000 food boxes for people in need.

Another example is, a patient with diabetes who was living in a tent—and without electricity to safely store his medication—had a powerful turnaround thanks to Bayhealth’s screenings and data tracking. The patient also had trouble seeing because of untreated cataracts.  

“Since engaging in chronic-care management, he now has an apartment, he received cataract surgery, and he believes in himself,” Istenes said. “His health outcomes have skyrocketed all because somebody cared for him.”

Altogether, Bayhealth’s approach toward implementing value-based care has been centered on the concept that “prevention is better than cure,” said Dr. Gupta.

“When we say we’re affecting one life at a time, it’s literally our motto,” said Hudson. “It’s what we live by. It’s heartening to work for an organization that makes that vision a reality.”

Learn  how to advance value-based care with alternative payment models in Medicare, part of the AMA Medicare Basics series.