A Clinical Care Pathway to Provide Value-Based Care to Patients Hospitalized with CHF, COPD, and Pneumonia

Managing the imbalance between job demands and available resources in the healthcare system is increasingly challenging. These growing demands include cognitive demands arising from diagnostic challenges; constant updates to guideline-directed medical therapy (GDMT); demands to satisfy patients in the face of insufficient resources, particularly time; and a lack of alignment. It’s often unclear as to how to balance job demands and resources. However, the bar will continue to rise, pushing toward better care coordination, better quality outcomes, reduced costs, and more value-based patient-centered care. We approached the challenge of managing hospitalized patients with CHF, COPD, and pneumonia as a team, using data analytics and project management approaches to design a clinical care pathway. This pathway included a sequence of critical steps; each step was assigned to an accountable stakeholder, allocated a time box, and tied to deliverables. The care pathway improved vertical alignment between our team and senior leadership’s quality and cost demands and solidified horizontal alignment among our teams’ stakeholders. This resulted in a sustained improvement in our quality outcomes, including more than 20% improvement in length of stay, increased adherence to GDMT, reduction in costs, and the creation of a better value-based care model.