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Module 6: Systems Based Practice (SYST)

Thumbnail of downloadable Module 6 PPT Presentation.

The provision of accessible, continuous, and coordinated person-centered care for persons living with multiple chronic conditions (PLWMCC) through a system that incorporates a team approach, health information technology, and shared decision making1.

Making the Case for Systems Based Practice for Persons Living with Multiple Chronic Conditions (PLWMCC)

Structural aspects of the U.S. healthcare system constrain access to affordable, effective care for PLWMCC. The current system is characterized by a disease-based focus, from reimbursement to service provision, to research2. Current payment and reimbursement policies create incentives that do not optimize care for PLWMCC and may actually diminish rather than improve the quality of care3-5. Because most clinical trials exclude PLWMCC, limitations in the knowledge base further compromise the ability to create effective clinical guidelines6,7 . PLWMCC have complex care needs, including significant psychosocial needs, and this requires that practitioners move away from a single-disease focus to a more holistic approach that focuses on complex care.

PLWMCC and practitioners who provide care face many challenges, including managing the consequences of transitions of care, such as incomplete communication, duplicate testing, incomplete medication reconciliation, and limitations in the transfer of other essential information. In general, these and other challenges cannot be solved by an individual care provider. Instead, they require broader, systems level solutions to decrease the burden on individual practitioners, create synergies that lead to higher quality care, and make resources available to PLWMCC. Some examples include working with an interprofessional team and team members who practice to the full extent of their licenses, connecting to community-based resources, developing patient-specific care plans, and establishing effective communication processes8-10 .

Approaches such as theChronic Care Model11 and the Patient Centered Medical Home have been helpful efforts to redesign health systems that offer better care while improving clinical and financial performance. There is now movement beyond the standard Chronic Care Model and Patient Centered Medical Home to evidence-based models such as Accountable Care Organizations (ACOs). These new models link transitions of care and sophisticated levels of care management, involve risk stratification to determine the right member of the team to provide the needed level of intervention, and involve a team of providers from community-based agencies. New coalitions are forming to better address the breakdowns in communication that occur with care transitions. These approaches shift the health system's focus from reacting to the individual’s acute care needs to a proactive, broader emphasis on health goals, needs, and abilities that are necessary to achieve desired health outcomes. These models encourage the maximum participation of all members of the care team to provide timely, accessible services, and improve quality and safety12,13. The redesign of primary care systems includes adopting innovative strategies to incorporate preventive services and self-management support into care, empower practitioners to implement effective changes, and develop capacity for change and ongoing quality improvement.

Key elements of systems-based practice for PLWMCC include: panel and population management, interprofessional teams; communication among PLWMCC, practitioners, and others; use of quality improvement strategies; community based services and supports; health information technology (HIT), data-driven clinical decision making, patient engagement/empowerment and satisfaction with care, and how to influence social determinants of health within the context of the community.

  • Population management: A population health perspective emphasizes the complexity of multiple determinants of health – including medical care, public health, genetics, behaviors, social and environmental factors – and variation within populations. Population management tools and techniques can help healthcare systems improve the health outcomes of PLWMCC by examining aggregate data on clinical and social characteristics of patient and community cohorts. Understanding overall needs and trends allows provider teams to track and intervene appropriately on clinical problems, social determinants of health, coordination of health services and patient engagement/empowerment14.
  • Interprofessional teams: In addition to PLWMCC and their caregivers, an interprofessional team is comprised of healthcare providers and their staff (e.g., medical assistants and office staff), pharmacists, social workers, dieticians, care coordinators, community health workers, and providers of other community-based resources15,16. High functioning team-based care entails clarification of roles and responsibilities, development of conflict resolution processes, good communication processes, and commitment to the care plans for PLWMCC17. The comprehensive care plans should be accessible to all team members, regularly reviewed, and revised as health milestones are met and goals change18.
  • Communication: Regular, accessible, and reliable communication among all providers and across settings is essential to facilitating care transitions, medication management, and PLWMCC education4,19,20 . Practitioners, clinics, networks, and systems may have different preferences regarding methods of communication. Methods include electronic health records (EHR), email systems, telephone calls, faxes, paper-based charting, digital media applications, tele-education for interprofessional team conferences, or in-person meetings. Communication is dependent on organizational capabilities.
  • Quality improvement: Quality improvement (QI) consists of systematic and continuous actions that lead to measurable improvement in healthcare services and the health status of targeted groups. QI programs are now using iterative, rapid cycle quality improvement strategies as part of their ongoing quality program, examining structure and processes using the Plan, Do, Study, Act (PDSA) model50. Healthcare quality is the correlation between the level of improved health services and the desired health outcomes of individuals and populations21. Quality is directly linked to an organization's service delivery approach or underlying systems of care. A successful QI program uses the data to continuously evaluate programming and improve care. A system that is dedicated to analyzing and improving the care it provides will have more and better opportunities to serve PLWMCC and their families and caregivers21.
  • Health information technology: Advances in health information technology (HIT) and Health Information Exchanges (HIEs) play an increasingly important role in systems-based practice. For example, clinical decision support tools can deliver clinical practice guidelines at the point of care and facilitate improved medication safety22. HIT can enable after-visit summaries that may improve shared decision-making, coordination of care, and adherence to recommended plans of care23. Electronic health record (EHR) systems (defined as "an electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized practitioners and staff within one healthcare organization24") can facilitate workflow and improve the quality of care and safety. Adoption of EHR systems and participation in Meaningful Use activities are increasing. From 2001 to 2013, the proportion of office-based physicians (non-federally employed physicians providing direct patient care) using any type of electronic health record system rose from 18 to 78% 25. HIEs help share PLWMCC information across multiple providers and systems26, a strategy to overcome interoperability across many different EHR systems and to facilitate communication and coordination across settings of care.
  • Risk stratification: In an effort to improve care of PLWMCC while managing costs, risk stratification methods are used. Risk stratification uses demographics, medical conditions, care patterns, and resource utilization data to identify PLWCC most in need of medical care27. A variety of models identifies and stratifies patients for targeted interventions. Enhancing care through risk stratification ensures that people with higher levels of severity of illness receive more directed care.

Learning Objectives by Competency

Competencies and associated learning objectives are presented below for use by educators. The competencies apply to a wide variety of health professions students, faculty, and practitioners including physicians, nurses, psychologists, dentists, pharmacists, social workers, allied health professionals, care coordinators, as well as interprofessional teams. These competencies apply across the educational continuum, and can be discipline specific or interprofessional. Examples of learning objectives are provided below. Educators may tailor objectives for a specific healthcare discipline and for a specific phase of education.

SYST 1. Provide care that uses evidence-based practices that optimize interactions and demonstrate positive outcomes for PLWMCC.

Learning Objectives

  • Use population management strategies to optimize monitoring of person-centered care.
  • Maintain a library of clinical and community evidence-based resources that is accessible to the entire interprofessional team.
  • Designate a team member or members to ensure that a library of clinical and community evidence-based resources is accurate and timely.
  • Develop strategies, including provision of on-the-job training and continuing education opportunities, to keep the entire interprofessional team up-to-date on evidence-based practices.


SYST 2. Address fragmented healthcare, barriers and potential harms that may result from lack of population management and coordinated care services for PLWMCC.

Learning Objectives

  • Analyze available data to identify barriers to delivering the best quality care.
  • Conduct interprofessional team meetings to discuss inefficiencies in care provision.
  • Develop processes for communication with referral organizations.


SYST 3. Provide opportunities for engagement and community involvement at the practice and health system levels for PLWMCC.

Learning Objectives

  • Organize an interprofessional care team that includes PLWMCC, their families and caregivers, healthcare providers of multiple disciplines (including specialists), and providers of community-based resources.
  • Maintain an up-to-date registry of community-based resources to be used by PLWMCC, their family and caregivers, and the full care team.
  • Establish working relationships with community-based organizations, hospitals, ACOs, nursing homes, home health agencies and newly emerging consortia in order to provide PLWMCC resources that are accessible.


SYST 4. Use quality improvement strategies to improve standards of practice for managing MCCs.

Learning Objectives

  • Integrate principles of quality improvement into work processes, including problem solving and decision-making.
  • Use quality improvement data to guide management of the patient populations in clinics, networks, or systems,.
  • Implement a quality improvement activity to review data, implement suggested changes, and re-evaluate area(s) that needs attention.


SYST 5. Use information systems and technology to monitor health outcomes, and enhance communication and safety of care provided to PLWMCC.

Learning Objectives

  • Implement a clinic, network, or system-wide electronic health record system to provide information at the individual and PLWMCC-population levels.
  • Use HIT and HIEs to provide PLWMCC information such as after-visit summaries, referrals to available community-based resources, and links to additional person-centered information on their conditions.
  • Link with local Quality Improvement Organizations (QIO) and establish processes for reviewing data from information systems to ensure care is high quality, safe, effective, and focused on PLWMCC’s goals.


SYST 6. Use cost-effective strategies and resource stewardship to address MCC commonalities and disease-specific goals in caring for PLWMCC.

Learning Objectives

  • Implement a process that evaluates cost-effectiveness of polypharmacy review for PLWMCC.
  • Implement a system that is accessible, reliable, consistent, and secure to support clinical decision-making regarding care for PLWMCC.
  • Support transitions-of-care planning for PLWMCC.


SYST 7. Enhance the level of practice of the interprofessional team through risk stratification and optimizing scopes of practice of all team members.

Learning Objectives

  • Utilize a risk assessment tool to stratify patients by level of complexity and frailty in order to facilitate individualized, person-centered care by the interprofessional team.
  • Discuss with the interprofessional care team how to develop procedures and care plans based on PLWMCC risk stratification and monitor results.
  • Develop a care plan that enables each member of the care team to practice at their optimal skill set and scope of practice.


Selected Curricular Resources

The following is a list of curricular resources that address, at least in part, Systems Based Practice. Additional resources can be found in the MCC Education and Training Repository with live links.



1. Institute for Healthcare Improvement. (2014). In-Person Training Transforming the Primary Care Practice. Retrieved from http://www.ihi.org/education/InPersonTraining/TransformPrimaryCare/Pages/default.aspx .

2. Tinetti, M. E., & Fried, T. (2004). The end of the disease era. Am J Med, 116(3), 179-185.

3. Reuben, D. B., & Tinetti, M. E. (2012). Goal-oriented patient care--an alternative health outcomes paradigm. N Engl J Med, 366(9), 777-779.

4. Boult, C., & Wieland, G. D. (2010). Comprehensive primary care for older patients with multiple chronic conditions: "Nobody rushes you through". JAMA, 304(17), 1936-1943.

5. Boyd, C. M., Darer, J., Boult, C., Fried, L. P., Boult, L., & Wu, A. W. (2005). Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA, 294(6), 716-724.

6. Parekh, A. K., & Barton, M. B. (2010). The challenge of multiple comorbidity for the US health care system. JAMA, 303(13), 1303-1304.

7. Lugtenberg, M., Burgers, J. S., Clancy, C., Westert, G. P., & Schneider, E. C. (2011). Current guidelines have limited applicability to patients with comorbid conditions: a systematic analysis of evidence-based guidelines. PLoS One, 6(10), e25987.

8. Vanderwielen, L. M., Vanderbilt, A. A., Dumke, E. K., Do, E. K., Isringhausen, K. T., Wright, M. S., Enurah, A. S., Mayer, S. D., & Bradner, M. (2014). Improving public health through student-led interprofessional extracurricular education and collaboration: a conceptual framework. J Multidiscip Healthc, 7, 105-110.

9. Mariano, C. (1989). The case for interdisciplinary collaboration. Nurs Outlook, 37(6), 285-288.

10. Lewis, V. A., Larson, B. K., McClurg, A. B., Boswell, R. G., & Fisher, E. S. (2012). The promise and peril of accountable care for vulnerable populations: a framework for overcoming obstacles. Health Aff (Millwood), 31(8), 1777-1785.

11. Glasgow, R. E., Orleans, C. T., & Wagner, E. H. (2001). Does the chronic care model serve also as a template for improving prevention? Milbank Q, 79(4), 579-612, iv-v.

12. Agency for Healthcare Research and Quality (AHRQ). Patient Centered Medical Home Resource Center. (2014). Retrieved from http://www.pcmh.ahrq.gov/page/defining-pcmh .

13. Agency for Healthcare Research and Quality (AHRQ). Health Care/System Redesign (2014). Retrieved from http://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/#tiptop .

14. Association for Prevention Teaching and Research. (2014). Clinical Prevention and Population Health Curriculum Framework. Washington D.C.

15. Trikalinos, T. A., Segal, J. B., & Boyd, C. M. (2014). Addressing multimorbidity in evidence integration and synthesis. J Gen Intern Med, 29(4), 661-669.

16. Campbell-Scherer, D. (2010). Multimorbidity: a challenge for evidence-based medicine. Evid Based Med, 15(6), 165-166.

17. Agency for Healthcare Research and Quality (AHRQ). Clinical-Community Linkages. Retrieved from http://www.ahrq.gov/professionals/prevention-chronic-care/improve/community/ .

18. Harris, M. F., Dennis, S., & Pillay, M. (2013). Multimorbidity: negotiating priorities and making progress. Aust Fam Physician, 42(12), 850-854.

19. O'Malley, A. S., Tynan, A., Cohen, G. R., Kemper, N., & Davis, M. M. (2009). Coordination of care by primary care practices: strategies, lessons and implications. Res Brief(12), 1-16.

20. Brown, R., Reikes, D., and Peterson, G. . (2009). Features of Successful Care Coordination Programs: Webinar on Care Management of Patients with Complex Health Care Needs. Robert Wood Johnson Foundation: Mathematica Policy Research

21. Health Resources and Services Administration (HRSA). Quality Improvement Methodology. Retrieved from http://www.hrsa.gov/quality/toolbox/methodology/qualityimprovement/ .

22. Singh, R., Anderson, D., McLean-Plunkett, E., Brooks, R., Wisniewski, A., Satchidanand, N., & Singh, G. (2012). IT-enabled systems engineering approach to monitoring and reducing ADEs. Am J Manag Care, 18(3), 169-175.

23. Pavlik, V., Brown, A. E., Nash, S., & Gossey, J. T. (2014). Association of patient recall, satisfaction, and adherence to content of an electronic health record (EHR)-generated after visit summary: a randomized clinical trial. J Am Board Fam Med, 27(2), 209-218.

24. Agency for Healthcare Research and Quality (AHRQ). Electronic Medical Record Systems. (2014). Retrieved from http://healthit.ahrq.gov/key-topics/electronic-medical-record-systems .

25. Hsiao C-J, H. E. Use and characteristics of electronic health record systems among office-based physician practices: United States, 2001–2013. NCHS data brief, no 143. Hyattsville, MD: National Center for Health Statistics. 2014.

26. Yoder, D. (2011). Health Information Exchange. Information and Communication Technologies in Healthcare. Boca Raton, FL: Taylor & Francis Group, LLC.

27. Ensslin, B. & Barth, S. (2014). Risk stratification to inform care management for Medicare-Medicaid enrollees: State strategies. Center for Health Care Strategies, Inc.

28. Stewart, M., Brown J.B., and Freeman, T.R. (2003). Patient-centered medicine: transforming the clinical method: Radcliffe Publishing.

29. Gilbert, A. L., Caughey, G. E., Vitry, A. I., Clark, A., Ryan, P., McDermott, R. A., Shakib, S., Luszcz, M. A., Esterman, A., & Roughead, E. E. (2011). Ageing well: improving the management of patients with multiple chronic health problems. Australas J Ageing, 30 Suppl 2, 32-37.

30. Ryan, R. E., & Hill, S. J. (2014). Improving the experiences and health of people with multimorbidity: exploratory research with policymakers and information providers on comorbid arthritis. Aust J Prim Health, 20(2), 188-196.

31. Kindig, D., & Stoddart, G. (2003). What is population health? Am J Public Health, 93(3), 380-383.

32. Vogeli, C., Shields, A. E., Lee, T. A., Gibson, T. B., Marder, W. D., Weiss, K. B., & Blumenthal, D. (2007). Multiple chronic conditions: prevalence, health consequences, and implications for quality, care management, and costs. J Gen Intern Med, 22 Suppl 3, 391-395.

33. Boling, P. A. (2009). Care transitions and home health care. Clin Geriatr Med, 25(1), 135-148, viii.

34. Administration for Community Living (ACL). Aging & Disability Resource Centers Program/No Wrong Door System. (2014). Retrieved from http://www.acl.gov/Programs/CIP/OCASD/ADRC/index.aspx.

35. Rich, E., Lipson, D., Libersky, J., Parchman, M. Coordinating Care for Adults With Complex Care Needs in the Patient-Centered Medical Home: Challenges and Solutions. White Paper (Prepared by Mathematica Policy Research under Contract No. HHSA290200900019I/HHSA29032005T). AHRQ Publication No. 12-0010-EF.Rockville, MD: Agency for Healthcare Research and Quality. January 2012.

36. Soubhi, H., Bayliss, E. A., Fortin, M., Hudon, C., van den Akker, M., Thivierge, R., Posel, N., & Fleiszer, D. (2010). Learning and caring in communities of practice: using relationships and collective learning to improve primary care for patients with multimorbidity. Ann Fam Med, 8(2), 170-177.

37. Ferrante, J. M., Cohen, D. J., & Crosson, J. C. (2010). Translating the patient navigator approach to meet the needs of primary care. J Am Board Fam Med, 23(6), 736-744.

38. Woolf, S. H., Dekker, M. M., Byrne, F. R., & Miller, W. D. (2011). Citizen-centered health promotion: building collaborations to facilitate healthy living. Am J Prev Med, 40(1 Suppl 1), S38-47.

39. Mancini, J. A., Marek, L. I. (2004). Sustaining Community-Based Programs for Families: Conceptualization and Measurement Family Relations, 53(4), 339-347.

40. O'Malley, A. S., Grossman, J. M., Cohen, G. R., Kemper, N. M., & Pham, H. H. (2010). Are electronic medical records helpful for care coordination? Experiences of physician practices. J Gen Intern Med, 25(3), 177-185.

41. Going Lean in Health Care. IHI Innovation Series white paper. Cambridge, M. I. f. H. I.

42. Scoville R, L. K. (2014). Comparing Lean and Quality Improvement. IHI White Paper. . Cambridge, Massachusetts: Institute for Healthcare Improvement (Available at ihi.org).

43. Langley, G. L., Moen, R., Nolan, K.M., Nolan, T.W., Norman, C.L., & Provost, L.P. . (2009). The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd ed.). San Francisco: Jossey-Bass Publishers.

44. Schroeder, R. G., Linderman, K., Liedtke, C., Choo, A.S. . (2008). Six Sigma: Definition and underlying theory Journal of Operations Management, 26, 536-554.

45. HealthIT.gov. Meaningful Use Definition and Objectives. (2015). Retrieved from http://www.healthit.gov/providers-professionals/meaningful-use-definition-objectives .

46. Lau, M., Campbell, H., Tang, T., Thompson, D. J., & Elliott, T. (2014). Impact of patient use of an online patient portal on diabetes outcomes. Can J Diabetes, 38(1), 17-21.

47. Guthrie, B., Payne, K., Alderson, P., McMurdo, M. E., & Mercer, S. W. (2012). Adapting clinical guidelines to take account of multimorbidity. BMJ, 345, e6341.

48. Centers for Medicare & Medicaid Services (CMS). Chronic Care Management Services. (2015). Retrieved from http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf.

49. Camden Coalition of Healthcare Providers. Thinking About Risk Stratification. (2015). Retrieved from http://www.camdenhealth.org/cross-site-learning/resources/data/thinking-about-risk-stratification/ .

50. Just, E. (2014). Understanding Risk Stratification, Comorbidities, and the Future of Healthcare. In Health Catalyst (Ed.).

51. Stevens, D.P., Bowen, J.L., Johnson, J.K., Woods, D.M., Provost, L.P., Holman, H.R., Sixta, C.S. & Wagner, E.H.. (2010) A Multi-Institutional Quality Improvement Initiative to Transform Education for Chronic Illness Care in Resident Continuity Practices. J Gen Intern Med 25(Suppl 4):574–80. DOI: 10.1007/s11606-010-1392-z

Content created by Assistant Secretary for Health (ASH)
Content last reviewed on July 1, 2015