Physician / Clinician Organizations





AllCare IPA: Customized APM Development
The Attune APM Process

The Attune APM Process (click to enlarge)

AllCare Independent Practice Association (IPA), located in southwest Oregon, was established in 1994 to manage contracting with commercial payers for its 80 members. In the late 90s, it expanded operations with a capitated contract to provide managed Medicaid services in Oregon. Since then, Oregon has led the nation in transforming its Medicaid program to a Care Coordination Organization (CCO) model of care. In 2012, AllCare IPA was awarded a CCO contract and now services 55,000 Medicaid beneficiaries across a three-county service area. It ranks among the most successful CCOs in the state.


The IPA’s leadership team saw the transformative potential of well-designed Alternative Payment Models (APMs). And, they wanted access to APM expertise at the Centers for Medicare & Medicaid Services (CMS) to develop their Medicaid APMs.


Attune Healthcare has supported AllCare throughout their transition to the Coordinated Care Organization model of care. To meet the challenge of developing Medicaid APMs, AllCare engaged Michelle Vest, a Senior Partner at Attune, to draft an APM grant proposal to CMS. Michelle researched the CMS demonstration projects in physician, hospital, and ACO APMs, and the APMs developed by the Healthcare Payment Learning & Action Network. Working with the AllCare leadership team, she drafted a grant proposal for a next generation of APMs for primary care, specialists, behavioral health, oral health, and facility providers that would apply the accumulated wisdom of CMS research. It resulted in a $1.6M grant award to AllCare to develop its APM program.

First, Michelle defined and initiated the reporting and feedback loop with CMS for the grant. Then, she worked with the IPA’s financial and clinical leaders to define an equitable process for APM development with AllCare providers. She facilitated the first APM committee in primary care, and helped to define the roles of CCO staff needed to manage the APM program successfully. Barbara Wall, another Attune partner, developed criteria for AllCare’s hugely successful primary care APM. Michelle continued to guide the management team through the development of APMs for specialists, behavioral health, oral health providers and facilities.


It is clear from the AllCare experience that APMs serve as a major and rapid catalyst for change. The AllCare Medicaid primary care APM has resulted in a $3,000 to $50,000 annual payout per individual PCP for meeting quality and cost performance goals. AllCare’s results from primary care, specialist, behavioral health, facility, and oral care APMs demonstrate that the most expedient way to positively transform the healthcare delivery system includes well-designed APMs. Attune created and successfully realized an efficient process to develop and fully implement effective APMs. This process ensures transparency and achieves lasting results to bend the cost curve down, and improve the experience and quality of patient care.

Here are three of the crucial components to APM success we apply in each APM project:

  1. Reward clinicians for being strong stewards of our healthcare dollars, without compromise on the quality of clinical care and patient outcomes
  2. Ensure that clinicians lead the design and development process, and
  3. Deliver on promises and reward clinicians who actively engage in pursuit of better health, a better patient experience, at a lower cost.

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The Polyclinic: Clinical Integration Network Business Plan

shutterstock_414693964The North West Medical Group Alliance (NWMGA) invited The Polyclinic to lead this coalition of independent practices in the development of a Clinically Integrated Network (CIN). The Polyclinic engaged Barbara Wall and Michelle Vest, to develop an integrated model of care for this state-wide CIN, and strategies for Payer and Provider engagement. This was the foundation of a business plan to attract capital investment in the CIN.


The Polyclinic wanted a sophisticated integrated care model to attract investors experienced in risk management. And, CIN strategy would need to support practices with a range of experience in population management.


The Attune partners began with an analysis of Washington State’s population and demographics, and compared them to availability of independent practices. The results demonstrated viability of a key strategy for the CIN: enough independent physician practices to meet network adequacy requirements across the state. Attune’s assessment of NWMGA practices revealed that The Polyclinic was its only member with the analytical tools and infrastructure to perform effective population health management, but practices with minimal experience in population management would be needed for complete network. With the support of The Polyclinic’s leaders, Attune formulated a provider engagement strategy with flexibility – practices have the option to access The Polyclinic’s technology, analytics, and care management staff for management of complex populations.

Asthma Protocol (click to enlarge)

Asthma Action Plan (click to enlarge)

Low Back Pain Protocol (click to enlarge)

Then, Attune developed a state-of-the-art integrated care model to improve outcomes and costs. Next, Attune offered a Primary & Specialty Care Transformation Training Program for CIN practices to lead them up the population management learning curve with a starter set of evidence-based Condition Management Protocols to manage their risk. Click on the graphics to see Condition Management excerpts.

At the same time, Attune developed a Payer Engagement Strategy for the CIN and honed the premium and network criteria for the CIN through interviews with seven commercial carriers to provide the information needed for financial projections in the business plan.


Through creative collaboration with Attune, The Polyclinic created strategies and an integrated model of care designed to provide sophisticated population health management support to a network of providers with new to it. And, Attune contributed to a comprehensive CIN business plan that became the basis of significant funding from investors experienced in risk management.



Patient Centered Primary Care Institute: APM Implementation

APM Implementation Process (click to enlarge)

After developing an education and support network for Patient Centered Primary Care Home Practice Coaches, the Oregon Patient Centered Primary Care Institute found that they needed an expert in APMs to prepare Coaches to implement APMs successfully.


The Practice Coaches needed a method to evaluate their practices’ development needs and instruction on how to create an APM implementation plan. The Institute engaged Barbara Wall, who is contracted to Qualis Health and Washington State as their APM expert in Practice Transformation. Barbara is a Senior Partner at Attune Healthcare.


Customized Care Model (click to enlarge)

Barbara developed an online training session for the practice coaches. It laid the groundwork for an action plan by explaining foundational concepts in risk contracting and APM models. Then, Barbara summarized the results of CMS research into PCMH practice activities that produced significant cost savings and quality improvements in APM demonstration projects. Next, she presented a clear and coherent 5-step process for implementation of APMs by primary care practices that was created by Attune Healthcare Partners. Last, Barbara explained the downloadable Practice Assessment Tool that Attune created for practices to analyze the value of their FFS and APM contracts, and to evaluate their performance on them. The training explains the process to execute these 5 steps:

  1. Develop a Value Based Strategy
  2. Select an Integrated Model of Care
  3. Analyze Existing FFS & APM Contracts to Define a Services & Revenue Transition Plan
  4. Implement your Model of Care
  5. Align Incentives and Implement Performance Measures

Analyze FFS & APM Contracts (click to enlarge)

The Practice Coaches received a clear and coherent framework to use in evaluating their current contracts, identifying an integration strategy that will work for their particular practice, and measuring performance on current and future APM contracts. The practice coaches received examples and access to download the Attune Practice Assessment Tool. In training session evaluations, Practice Coaches affirmed they understood and could use the 5-step process in their primary care practice.

Hospitals & Health Systems

Fred Hutchinson Cancer Research Center: Integration of Three Powerhouses

shutterstock_227607844After deciding to develop a new ambulatory model of care to be located in a state-of-the-art cancer treatment center, Fred Hutchinson Cancer Research Center (FHCRC) called upon Attune Senior Partner Michelle Vest, and Harold Nesland, the Managing Director of Global Design Solutions, to develop a strategy and facilities plan for an Ambulatory Cancer Care Center in Seattle, Washington.


Their challenge was to:

  • Evaluate an option for a stand-alone program, as well as an option in which other area cancer care leaders and historical competitors would become program partners
  • Study market demand, define care programs, develop the operating model and program costs, and quantify the capital requirements for a comprehensive ambulatory program, and
  • Develop a unified program and facility plan for an Ambulatory Cancer Care Center, to be nationally recognized as best in class in quality, with services delivered at a competitive cost.

(click to enlarge)

Harold and Michelle focused initially on regional and national market demand, then worked with FHCRC leaders to define the new ambulatory care model. From the model, they defined care programs, an operating model, and operational costs. Finally, they created an overarching financial analysis, projecting revenues and quantifying capital needs for the program.

Their initial conceptualization of the program allowed FHCRC to engage in meaningful discussions with University of Washington Medical Center and Seattle Children’s Hospital about the new care model and the roles of the three organizations in partnership, thereby expanding the scope of the project.

The expanded project now included the integration of the three powerhouse organizations in cancer care, including where specific services would be delivered in partnership—with each of the three continuing operations as separate entities. The new challenge was to create a plan for integrated, ambulatory care in which the three organizations would continue to provide the highest care quality, but at a more competitive cost than they had historically as separate entities. This integrated, competitively priced ambulatory care model would be the lure to attract patients and payers from around the country. In time, this fourth, integrated organization was named Seattle Cancer Care Alliance (SCCA).

Michelle, then a Principal at Arthur Anderson, was charged with developing a market strategy and financial analysis for SCCA and how it would integrate with each of the three partners. Working with the partners, she developed a model for integrated care delivery and the origination of program services for the four organizations. She developed a financial analysis and pro forma for each, and facilitated discussions of service delivery at SCCA that would be in the best interest of all.

Harold, then a leader in Yuan Nesland Associates, developed the staffing, functional program, space program, and master development plan. The lean operational analysis he created informed the development of the service delivery program and the capital development plan. After the program development, Harold continued on as a design consultant responsible for the interior architecture of the project to ZGF, the Architect of Record.

The two consultants collaborated to create an integrated development plan that met the following objectives:

  • Provide for full integration of research, clinical trials, and clinical care programs with a positive ROI to the partners
  • Incorporate the latest technology, yet provide for future flexibility in design, and
  • Consolidate outpatient services into a single full-service ambulatory center at the highest level of quality, competitively priced.

shutterstock_362968433These combined efforts in business planning, program development, space planning, and capital planning resulted in the construction of the 154,000 SF Seattle Cancer Care Alliance Facility, with an open-ended, phased-expansion pathway. Last year, 30,000 people from around the world came to SCCA for evaluation, comprehensive treatment, clinical trials, and second-opinion consultations. The SCCA program brought the three area powerhouses in cancer care together into a seamless, competitively priced program that met the ROI requirements of the partners and the quality and service demands of the national market in a progressive, ambulatory model of care. The accolades of this world-famous integrated cancer care alliance include the following from U.S. News & World Report:

  • The SCCA/UW Medicine in the top 10 Best Hospitals in the Nation for Adult Cancer Treatment for the last decade
  • In 2015, SCCA/UW Medicine as the 5th Best Hospital in the Nation for Adult Cancer Care and SCCA’s Seattle Children’s Hospital was ranked as 6th Best Children’s Hospital in Cancer Care, and
  • SCCA/UW Medicine was scored as “Highest” in Survival, Nursing Intensity, Patient Volume, Advanced Technologies, and Patient Services.
Silver Cross: Hospital Repurposing

shutterstock_180435416-1Silver Cross Hospital, located in Joliet, Illinois, became the subject of community outrage when the hospital proposed to abandon its 700 bed hospital in Joliet, and build a new facility in a neighboring town, six miles away.


The hospital responded by forming a community advisory council, engaged a consulting team, and began to explore ways to “repurpose” the Joliet hospital campus. The goal of the exploratory effort was to prepare a redevelopment plan that would enhance the surrounding community of Joliet without creating an economic drain on the hospital system.


The hospital engaged Michelle Vest, Senior Partner in Attune Healthcare, in collaboration with the Chicago-based real estate firm, Caldwell Banker, as their consultants to create a redevelopment plan for the Joliet campus.

First, the consulting team identified buildings that the hospital could use for non-clinical support services such as business office functions, warehousing, and information technology support. Next, they identified the newer, clinical wings of the old campus that still had a significant “remaining useful life” and might attract replacement healthcare organizations. They targeted organizations with interests in healthcare like the Veterans Administration, agencies that serve developmentally disabled persons, behavioral health providers, child care services, school programs for youth, senior services, skilled nursing, and even prison health. Then, the team identified potential occupants outside of the healthcare industry interested in total redevelopment of the facilities to support education, retail, commercial offices, and the transportation industry. The fact that the Joliet campus was located across the highway from one of the nation’s largest railroad transportation hubs presented some unique repurposing options for consideration.

Working with Silver Cross leadership, the consulting team helped the council and leadership to understand the identified opportunities against pre-defined repurposing criteria. The community advisory council gave input, and top priorities were discussed with elected officials at the city, state, and national level. When clear preferences had been identified, the preferred options were presented to the hospital board of directors, and approval was granted to proceed.


shutterstock_204678406-1What had started out as a highly contentious, politically charged controversy surrounding the hospital’s relocation plans, was transformed into a positive rebranding of the hospital system’s image.

The final repurposing plan for the Joliet campus included: 1) continuation of hospital support functions on site, 2) federal funding to develop and implement a Veterans Administration clinic, 3) relocation of developmental disabilities programs to newer portions of the hospital, and 4) long term redevelopment of other parts of the campus to support the railway transportation hub.

In the final analysis, the repurposing plan developed by the consulting team created a valuable community asset for the city of Joliet, and a financial boon for the hospital system. And, the hospital system’s community relationships in both cities were strengthened.

Health Plans


AllCare Health: Population Health Management Program

When Oregon expanded its eligibility criteria for Medicaid, AllCare Health Plan forecasted it would double its membership from a high-risk group with little or no access to regular healthcare before enrollment. AllCare called on Attune Healthcare to develop a Population Health Management strategy to control their risk for new members with pent-up demand for services.


AllCare needed to identify individuals and populations at risk quickly, proactively meet member needs, and manage its risk—all without compromising care quality.


Michelle Vest and Barbara Wall, Senior Partners at Attune, developed a short, intermediate, and long term approach for managing high-risk populations for the health plan. First, Barbara developed a Health Risk Assessment that identifies new members who needed immediate care or have costly chronic conditions, and AllCare’s Care Management Department wrapped it into their new member on-boarding process. Second, Barbara developed Care Pathways to manage patients with high-cost chronic conditions, using evidence-based action plans to engage members and their PCPs in symptom recognition and control. She collaborated with the Chief Medical Officer to develop a communication plan promoting practice training and adoption of the pathways. Next, Barbara developed a high-impact Care Transitions program for the health plan. It raises the Program’s ROI by use of a Readmission Risk Assessment to focus prevention efforts on the highest risk patients. Last, Michelle Vest worked with the health plan’s CMO, business analysts, and IT personnel to select and implement predictive modeling tools for preemptive intervention. With the new business intelligence tools, Michelle led the team in an analysis of outliers in utilization—which revealed new areas of opportunity for Population Management.

Chronic Condition Management Program (click to enlarge)


The short-term strategy that Attune developed allowed the health plan to avert a wave of acute care expense, and to provide new members the care and attention they needed in a Patient Centered Primary Care Home. The Care Management staff were able to use the Health Risk Assessment to identify new members in dire need of care and expedite intervention to avoid medical crises. Care Pathways support management of AllCare members at an intermediate level of risk, and stabilizes their condition with coordination from their primary care providers. The business intelligence tools developed with Attune provide a longitudinal tactic for risk management that decreases the development of health risks into active illness with acute, costly episodes.

Discharge Risk Assessment (click to enlarge)

AllCare Health: Care Management Department Redesign

It is very difficult to fully engage small, rural primary care practices in health system transformation. Typically, they do not have access to skilled staff to coordinate care or integrate with behavioral health providers. AllCare Health Plan’s provider network includes a significant portion of small, rural primary care practices.


AllCare Health engaged Attune Healthcare to develop an effective approach to providing coordinated care throughout their entire provider network, of the highest quality, with reductions in overall healthcare cost.


Michelle Vest and Barbara Wall, founding partners at Attune, helped AllCare Health develop a department of skilled personnel to coordinate care on behalf of small, rural clinics in the health plan’s network. This provided all members of the health plan the same high level of service, regardless of practice location or size.

Michelle and Barbara facilitated a department redesign initiative for case managers, utilization management nurses, social workers, chronic condition coaches, behavioral health specialists, and community health workers. They guided this multi-disciplinary team through a discovery of new models of care for behavioral health integration, transitions of care, care pathways for chronic conditions, home safety checks for frail populations, and a streamlined process of risk assessment of new enrollees. AllCare also employed Attune’s expertise to upgrade and customize their care management software to accommodate new work flows, improve documentation of care management activities, and monitor staff performance and outcomes.

Staff are now assigned in care management teams: each team includes a case manager, UM nurse, and a community health worker. This core team collaborates with primary care providers to coordinate their care plans with the physician’s treatment plan. Department specialists in behavioral health, chronic disease, obstetrics, pediatrics, and dental health are assigned to core teams as needed. Each team is responsible for a geographic territory in which collaborative partnerships with community-based programs are cultivated for smooth patient referrals, communication, and coordination.


Benefits of the program have been profound. Using tools developed by Attune, many patients are able to monitor and self-manage their chronic diseases. Staff are better prepared to coordinate care across care settings, and providers are better educated on referral criteria for care management. Savings from reduced emergency room visits, reduced readmissions, and care coordination have been achieved year after year by the health plan with a consistent high level of service and quality to patients assigned to all practices, large or small.

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State Governments


State of Oregon: AllCare CCO Transformation Plan


AllCare CCO Transformation Process (click to enlarge)

Landmark legislation in 2012 restructured Oregon’s healthcare system and created Coordinated Care Organizations (CCOs) to serve 1.2 million Medicaid beneficiaries. AllCare Health Plan was one of the 16 CCOs that contracted with the Oregon Health Authority to accept full risk and capitation for Medicaid members. Each health plan received a global budget to encompass physical, behavioral, and dental health services, and had to develop a new, value-based model of care to meet the State’s requirements for their individual Transformation Plan.


AllCare CCO’s Transformation Plan needed to use progressive strategies to implement eight required initiatives, and to deliver and sustain cost reductions and improvements in care. These included:

  1. Behavioral and Physical Health Integration
  2. Patient Centered Primary Care Homes
  3. Alternative Payment Models
  4. Community Health Needs Assessment and Improvement
  5. Electronic Data Efficiency and Telehealth
  6. Non-Traditional Workforce Development
  7. Health Equity and Improved Access, and
  8. Improvement in Care Quality, Costs, and Outcomes.

Attune Healthcare developed and guided AllCare in the implementation of a unique Transformation Plan, beginning with the initial plan in 2013, and expanding its goals for the community in each successive year. The Transformation Plan and process has evolved over time, and the CCO and its Board of Directors have assumed ever greater responsibility; first in improving healthcare delivery, and then in improving the health of their community.


By gradually shifting focus from improvements inside the delivery system, externally to the community, the health plan generated enough savings to fund significant investment in the community’s broader needs. Improvements in care coordination, reduction of waste and duplication, increased use of evidence-based care, and improved effectiveness of prevention programs drove early cost savings and achievement of quality benchmarks for the CCO. The savings generated by these early changes to the delivery system allowed the AllCare CCO Board to fund RN staffing in the public health department for Josephine County. Later, AllCare’s model of care generated significant community investment funds through an Alternative Payment Model initiative lead by Attune Healthcare Partners. These APMs promote use of lower cost care settings that resulted in equal or better outcomes, more effective care coordination, and new approaches to population health management. Attune Healthcare Partners supported these initiatives through strategic advisory services, project management, staff training, and development of tools to implement new care models. With the CCO’s continued financial success, the AllCare CCO Board recently approved $3.8 million to fund housing for the homeless, food for families, and education for early childhood development in their community.

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State of Oregon: Advanced Practice Learning Collaborative

graphics-pcpci-adv-learning-collabIn 2013, the Oregon Patient Centered Primary Care Institute contracted with Patient Centered Medical Home training experts for three Learning Collaboratives for practices at varying levels of accomplishment as medical homes. The Institute engaged Barbara Wall, a Senior Partner at Attune Healthcare, to develop a Learning Collaborative to lead groups at the Advanced level of recognition to full practice transformation.


Faculty leaders for each Learning Collaborative were given complete discretion to define curriculum to meet the State’s goals. Barbara developed a practice assessment for the Advanced participants, and invited the clinical and operational leads from each team to an individual interview learn about their medical home accomplishments and their goals for the Collaborative. The results showed unanimity in the practices’ desire for training in two subjects: behavioral health and primary care integration; and effective team based care and management of complex patients.


In the practice interviews, team leaders stressed the difficulty of managing patients with serious behavioral health diagnoses in addition to complex medical conditions. Therefore, Barbara selected behavioral health management as the focus of the first Advanced Learning Session, and recruited leaders in various models of behavioral health integration for it. Team leaders expressed a clear preference for experiential, or “lessons learned” educational content during the practice interviews, so Barbara included several multidisciplinary teams on the agenda to share their journeys in implementing unique integration models. One team described a Behavioral Health Consultant model, in which a clinical psychologist embedded in the PCP office provides brief counseling interventions with patients, and treatment consultations with the PCPs. Another team shared its success in reducing avoidable emergency room visits in patients with serious behavioral health diagnoses using Community Health Workers embedded in the PCP offices. And, Barbara shared lessons learned from her experience developing an integrated primary care program within a Community Mental Health Organization. The foundation in effective methods of behavioral health integration from the first Learning Session prepared the practice teams to tackle complex care management in the second Learning Session.

During the team interviews, Barbara discovered that the Advanced practice leaders were not familiar with the role of Case Managers in complex care management. Barbara developed a toolkit for complex care management for multidisciplinary primary care teams. In it she presented case management skills, tools, and tracking methods for patients with serious behavioral and medical conditions. It profiled and compared tools for evaluation of chronic medical and behavioral health conditions and care planning. And, the toolkit provided resources and criteria on how to effectively utilize staff in new roles in integrated care models, including case managers, social workers, behavioral health counselors, and community health workers.


6-4-1_csma_manualSuccessful cross-pollination between the teams occurred. Several teams adopted their own permutation of the integrated models of care that were presented with support from Collaborative faculty. All of the practices demonstrated successful application of at least one of the tools from the Care Management toolkit. And, the participant evaluations of these Learning Sessions produced some of the highest ratings of all the State’s Collaboratives.


State of Washington: PCMH Learning Collaborative


When the Washington State Patient Centered Medical Home (PCMH) Learning Collaborative was convened in 2009, a clear, coherent sequence for teaching the Medical Home model of care was not yet well established. Washington Practice Coaches were charged with facilitating the understanding and implementation of the PCMH core concepts in a wide variety of practice types. From solo practitioners still using paper charts, to large practices with residency programs, Practice Coaches had to find a way to order the principles, make them intelligible, and foster their spread in their assigned practices.


After the second of five Learning Sessions, it was clear that some of the smaller practices were struggling with translation of the PCMH vision into practice. There was a need to synthesize the core principles of PCMH into a coherent, step-by-step approach to the PCMH model of care for these practices—and to do so on a limited coaching budget.


pdsa-wheelBarbara Wall, a Senior Partner at Attune, was engaged as a PCMH Practice Coach to large and small Collaborative practices. She recognized that the small practices were having a hard time assimilating the core PCMH principles, and developed a sequential set of training modules in PowerPoint for them. Any one of the four modules could be selected to meet a practice at their current point on the PCMH learning curve. With a limited Collaborative budget in mind, Barbara identified a Coach in each struggling practice and trained the Coach and their physician champion using the modules. Thereafter, she mentored the Champion-Coach pair in training the rest of the practice with the slide decks. The four modules in the deck covered the fundamentals of PCMH start up:

  1. Quality Improvement process, including the concepts of patient populations and sub-populations, and the principles of evidence-based care and reduction of variation in care
  2. Development and use of patient registries, including how standardized Clinical Quality Measures are commonly structured, and how to analyze Clinical Quality Measures to create reporting queries
  3. Creation of work flows for patient tracking, outreach, huddles, and planned care processes to improve care of populations, and
  4. Use of protocols to improve data and process flows, working to the top of license within teams, and max packing visits to increase receipt of appropriate preventive care.

The teams that were struggling to translate the PCMH concept into practice were able to zero in on how to execute the fundamentals that supported their practice goals. With some remedial work on basics within the small practices, they were able to report Clinical Quality Measures and demonstrate improvement in their results. Even the small practice still on a paper chart system was able score in the top 10% of the Collaborative on their Clinical Quality Measure results after individualized coaching on the PCMH concepts.

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