Propel your value-based care strategy forward in 2023 with these four critical steps


Let’s face it. Value-based care (VBC) is what every physician strives to provide. It’s about giving patients the care they need and deserve—care that improves outcomes and helps patients lead happier, more fulfilling lives.


To do this, forward-thinking healthcare organizations need a value-based care strategy—not just any strategy but one that makes good financial sense in a largely fee-for-service (FFS) payment environment. This means organizations must empower existing staff to work more efficiently and effectively at identifying patients for VBC initiatives.


Consider these four steps to move the needle on value-based care in 2023 and beyond:


1. Enroll eligible patients in Chronic Care Management (CCM). Being able to easily enroll eligible patients in a formal CCM program is paramount. The good news? With the help of technology, there’s no guesswork and no missed opportunities. CCM is an important first step toward VBC because it promotes positive outcomes and lower costs through enhanced care coordination and ongoing patient engagement. CCM is also a billable service that Medicare and many commercial payers reimburse.


2. Close care gaps. When it comes to closing care gaps, where do providers even begin? The answer is not to hire dozens of care coordinators and chronic care managers. Instead, it’s about leveraging technology to augment existing staff capabilities. For example, cancellations and no shows are often the root cause of many care gaps. By generating daily reports, staff can follow up with patients directly to reschedule appointments as needed.


In addition, the annual wellness visit, CCM visits, and even sick visits are all opportune times to identify and address these gaps in care, but only when actionable clinical insights are available at the point of care. For instance, rather than combing through the electronic health record to see whether patients had their breast cancer screening, technology can easily deliver this information to physicians and their staff during the visit. This same technology combines EHR data with data from a variety of external sources (e.g., the U.S. Food and Drug Administration, U.S. Census Bureau, Centers for Disease Control and Prevention, American Heart Association, American Diabetes Association, and others) to assign individual risk scores and help providers and staff address care gaps in real-time. Again, it’s about working smarter—not harder.


3. Collect data on social determinants of health (SDOH). So many aspects of VBC occur outside a healthcare organization’s four walls. This means if healthcare organizations truly want to provide VBC, they must look at the bigger picture. The first step is to collect SDOH data related to patients’ economic stability, education, race, ethnicity, language, and more. The next step is to use this information to provide culturally competent care, inform treatment plans, and promote health equity.


Ask this question: Does your healthcare organization have a way to capture and ingest SDOH data into your EHR? Does it know how to use this data to improve patient engagement?


4. Form external partnerships. To create a solidified strategy for return on investment, healthcare organizations may need to form partnerships with community-based organizations (e.g., faith-based organizations, housing units, schools, and other non-profit organizations) that can help them address patients’ needs. For example, if a healthcare organization identifies higher rates of uncontrolled hypertension in certain populations, it can engage community organizations to provide education and potentially even host blood pressure screening events. Together, these entities may even be able to participate in and derive financial benefits from value-based care initiatives such as ACO REACH and Primary Care First.


When thinking about external partnerships, an important first step is to identify high-risk, high-cost patient populations. Then find community partners with an intimate understanding of and deep connection to these populations and collaborate on ways to work together toward common goals.



Your 2023 VBC strategy doesn’t necessarily require a significant financial investment, nor does it require more staff. By leveraging technology, healthcare organizations can provide VBC even in a largely FFS environment. As FFS contracts continue to shift toward VBC, the payoff will be even greater through the alignment of financial incentives.


About DignifiHealth

DignifiHealth partners with health systems on value-based healthcare, chronic disease management, care gap closure, and more to create exceptional patient and health system results. To learn more, visit