Case study: How Oak Street Health keeps its elderly patients happy and healthy

By Aine Cryts

Keeping dual-eligible seniors happy and healthy is a tough nut to crack. But Chicago-based Oak Street Health has done it in a value-based care model, according to a recent article in NEJM Catalyst by Griffin Myers, M.D., Geoff Price and Mike Pykosz, founders and part owners of the practice.

The average patient at Oak Street Health is a 73-year-old woman--55 percent of its patients are women--and likely has serious health issues, such as diabetes (24 percent of patients), congestive heart failure (17 percent) and major depression (12 percent). The practice operates a globally capitated, at risk model, where it's financially on the hook for all of its patients' care. Still, Oak Street Health has been able to reduce its seniors' hospitalizations by 40 percent while receiving a five-star HEDIS rating, write the practice's leaders.

Here's what helps Oak Street Health achieve these outcomes:

Leveraging data to drive access to care resources. Patients are organized into one of four tiers based on their age, co-morbidities, utilization patterns and access to a personal support network. For instance, Oak Street Health wants to see its sickest patients--who comprise 5 percent of its patients--every three weeks. The practice's healthiest patients are seen far less frequently, the authors write.

Devoting more resources to primary care. The health center invests in primary care--with appointments that last at least 30 minutes, on-site care managers to coordinate care across multiple providers, and transportation to and from patients' homes for appointments.

Using a team-based approach to care. Everyone on the care team--and that includes physicians, nurse practitioners, registered nurses, medical assistants, care managers and clinical informatics specialists--knows their precise role in the continuum of care. Daily team "huddles" are another mechanism the practice uses to make real-time decisions about providing care resources to the patients who need it most.

To learn more:
- read the article