Reshaping the Future: Care Transformation Through a Patient-Centered Approach

In a world where language like innovation, artificial intelligence (AI), strategy, value-based and disruption have become part of our lexicon, care transformation seems to merge these concepts. Organizations are adding chief transformation officers and care transformation teams, investing in care transformation consultants, and engaging with care transformation initiatives. 

As we enter 2025, I wanted to spend some time examining care transformation, how I believe we should be thinking about it, and how to transform care in the context of our programs. “Transform” is a two-part word with the prefix “trans’ and the root word “form.” The prefix “trans” has several meanings, but the one that resonates with me is “to change.” The root word “form” means “shape.” Pulling the roots of the word together, transform takes on the meaning to “change shape.” Simply put, care transformation means to change the way we shape care delivery for our patients. So where do we start?

I believe it starts with us – healthcare leaders who are willing to take a truly patient-centric approach to reconfigure care delivery. I often hear people in the healthcare field say, “until we get paid ‘differently’ or until someone else proves the success of a certain model, it’s hard to do anything differently.” Because care transformation starts with us, we have a unique opportunity, which in some ways is forced upon us. Recent challenges related to workforce shortages, patient volumes, challenging economics, reimbursement reductions coupled with technology advancements, pharmaceutical innovation and new delivery models have created an unprecedented level of disruption – the time is now. Economic pressure and patient preferences are shifting toward lower-acuity sites, reimbursement has expanded to a broader range of settings, and new medical technologies enable more care outside the hospital.¹ In the current climate, care delivery can and should be structurally changed.

Patient-centric care delivery begins with several key principles. You can’t go wrong by focusing on patient access and appropriate care in the right setting. Look across your delivery organization, and ask the following questions:

❓Where do you have challenges or subpar performance related to access?

❓Where are you finding that you may be delivering care in the wrong place or by the wrong people? Make a list.

❓Which ones do you want to tackle in 2025?

❓How do we change the way we deliver care in those areas?

Let’s run your list through the following framework:

1. Right People: In the last two decades, we have seen the cardiovascular clinical workforce expand beyond the traditional physician, nurse and medical assistant model. Team-based care has become the “norm” through the use of advanced practice providers. We are seeing great headway in expanding access and providing appropriate care to our cardiovascular patients in this model. In 2025, we have an even bigger opportunity to expand our teams with pharmacists, nutritionists, community health workers, nurse coordinators, exercise physiologists, etc. As you look to transform your care model, start with the care objective you are seeking to achieve and apply a new lens not focused on your current team. If you could start from scratch, who are the best clinical professionals to contribute to the care delivery. You may be surprised at the answer you will find.
2. Right Place: It’s been more than a decade since we started transitioning care from the hospital setting to the practice setting. We realized that sending patients to the emergency department or hospital was not required if we established the appropriate support model in our clinics. We saw the addition and evolution of heart failure clinics, urgent care clinics, same-day appointments, nurse triage teams, etc. In 2025, we need to start thinking about care at home. With ambulatory spaces and resources that are typically over capacity, what are some of the care objectives that can and should be delivered at home? Virtual care through advancing technology has become a proven care model with remote patient monitoring, telehealth and care management. If we were able to transition just 20% of the care in our ambulatory spaces to virtual care, how would your resources needs change? And what better way to provide patient-centric care than in the walls of their own home?
3. Right Technology: AI and digital tools are exploding in their capabilities and functions, but there are a few key considerations to bear in mind. Digital tools should build on established and successful solutions to improve patient care, team/physician experiences and operations. If the solution does not provide at least one of these benefits, then it is the wrong solution. Digital tools cannot and should not be the solution to substandard operations, wrong people or poor processes. However, when integrated into a well-defined care delivery model, they can be a great way to enhance or enable new care delivery methods.

Putting your ideas into action:

✔️Take your list of opportunities.

✔️Choose one or two care objectives to start.

✔️Define the right people to help you – those who currently deliver the care (or representatives), operation leaders (clinical and business), information technology and revenue cycle.  

✔️Carve out some time in a place (or digital space) with a large white board.

✔️Ideate – start with the care objective you are seeking to solve for and back into achieving that care objective using the right people, right place and right technology.

✔️Develop an operational plan.

As we step into 2025, I believe we have a year of opportunity. Opportunity to continue to develop our patient care model into one that’s more patient-centric. If we start with the outcomes we are seeking to achieve and develop the appropriate model to get us there, I am confident that we will also inadvertently achieve the other three pillars of the Quadruple Aim. Patient-centric care is cost effective because the framework helps healthcare leaders and providers avoid complications, shift care to the most appropriate location, and focus on prevention. Physician and team experience should prosper as the care is focused on the one thing that we all value – patients and their outcomes. Quality will be the result if we start with a plan focused on high-quality care and set ourselves up for that through the way we define and establish the delivery model. Finally, as we embark on 2025, we have something that many others do not – community. As part of the MedAxiom community, we can learn from each other and encourage one another. Community is part of the secret sauce – connecting with individuals in the cardiovascular community and seeking ways to transform care delivery to better meet the needs of our patients. Here’s to 2025!

1. Signal S, Underman D. How the Healthcare Industry Can Weather Ongoing Challenges. com. Published December 5, 2024. Accessed Jan. 2, 2025. https://www.mckinsey.com/industries/healthcare/our-insights/how-the-healthcare-industry-can-weather-ongoing-challenges.