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High-quality primary care doesn’t begin and end with a doctor’s visit. Learn how Eskenazi Health’s value-based care model empowers entire care teams to prevent illness, improve outcomes and create healthier communities.

For decades, primary care has largely been reimbursed based on the services delivered during a patient visit, but as health care continues to evolve, leaders at Eskenazi Health believe there is a better approach. Known as value-based care, this model recognizes that high-quality primary care extends far beyond the time a provider spends with a patient in the exam room. It requires a coordinated team working together before, during and after each visit to address medical needs and social drivers of health that can affect long-term wellness.  This allows the team to prioritize the care that the patient values the most.

“Research from the National Academies of Sciences, Engineering and Medicine shows that the work that truly keeps people healthy often happens outside the exam room,” said Dawn P. Haut, M.D., CEO of Eskenazi Health Center. “Primary care teams need to get paid to care for people, not providers to simply deliver services.”

At Eskenazi Health, this team-based philosophy has guided primary care for years. Providers, nurses, medical assistants, community health workers, social workers, dietitians, financial counselors, human resource team and many others play an essential role in helping patients navigate their health journeys. Together, they work to prevent illness, manage chronic conditions and connect patients with the resources they need to meet their health goals and thrive.

Implementing this model requires more than clinical expertise. It requires payment systems that support the work happening between visits. Team meetings, care coordination, outreach, community partnerships and patient navigation all contribute to better outcomes, yet historically have not been reimbursed under traditional fee-for-service models.

Haut points to an example of a fictional patient, “Mr. Parker,” used as a case scenario to highlight the value-based care model.  “Mr. Parker’s” story reflects the experiences of many patients living with multiple chronic conditions and the important supportive role their family members play in their care. Rather than reacting to medical crises as they arise, a value-based care model allows the entire care team to anticipate challenges, coordinate care between visits and address issues before they lead to emergency department visits or hospitalizations.

Value-based care shifts the focus toward prevention and more proactive solutions. While patients with complex medical needs significantly benefit from coordinated care, the greatest opportunity lies in identifying rising-risk patients before chronic disease develops.

“We want to help ‘Mr. Parker’ change his trajectory.  It is possible to reverse chronic conditions when we focus on whole-person care including mental and social health,’” Haut said. “If we can identify risks early and intervene before disease progresses, we can help people stay healthier longer and implement cost savings for the long term.”

Another critical aspect to value-based care is building trust with the patient that extends far beyond the exam room.

“Value-based care only works when patients trust the people caring for them,” explained Saura Fortin-Erazo, M.D., Eskenazi Health Center chief medical officer. “Sometimes that trust begins with the provider, but just as often it grows through a nurse, medical assistant or community health worker who connects with the patient in a meaningful way.”

Trust lays the foundation for value-based care, but achieving better outcomes depends on every member of the care team working together and contributing at the highest level of their expertise.

“Every member of the care team plays a vital role in improving health outcomes,” noted Donna Burks, MSN, RN, Eskenazi Health Center chief nursing officer. “When medical staff members are empowered to work at the top of their licenses, we strengthen the entire care team and allow patients to receive the support they need.”

The funding provided by Eskenazi Health Foundation helps support value-based care today, while leveraging philanthropy to strengthen reimbursement streams for the future. For example, the Foundation helped provide the addition of community health workers to the care team. Community health workers continue to play a vital role in supporting patients and strengthening the neighborhoods surrounding each health center.  In addition to direct patient support, they connect individuals to a wide range of essential resources, including Food is Medicine programs, and transportation and housing resources.

For Eskenazi Health, value-based care represents the next evolution of primary care. By investing in collaborative teams, strengthening community partnerships and focusing on prevention, the health system is demonstrating how high-quality primary care can improve health outcomes. To make this model sustainable, payment systems must evolve to reimburse the work that happens before, during and between patient visits, allowing care teams to continue delivering the proactive, coordinated care that leads to healthier communities. To learn more about primary care at Eskenazi Health, please visit https://www.eskenazihealth.edu/health-services/primary-care.