The Institute of Medicine's 2001 landmark report, “Crossing the Quality Chasm,”1 issued a rallying call for a fundamental redesign of the U.S. health care system. The report states that, “Research on the quality of care reveals a healthcare system that frequently falls short in its ability to translate knowledge into practice, and to apply new technology safely and appropriately,” and further notes the “absence of real progress toward restructuring healthcare systems to address both quality and cost concerns, or toward applying advances in information technology to improve administrative and clinical processes.”1 Since the publication of this report, the process of fundamentally changing the way care is delivered has been chaotic and challenging. Porter et al. observed that, “Despite many waves of debate and piecemeal reforms, the U.S. health care system remains largely the same as it was decades ago. We have seen no convincing approach to changing the unsustainable trajectory of the system, much less to offsetting the rising costs of an aging population and new medical advances. Today, there is a new openness to changing a system that all agree is broken.”2
In response to pressures resulting from skyrocketing health care costs, changing demographics, and shifting technologies for delivering and documenting care, the industry has mobilized around the notion of “value-based” care.3 Value-based care reimburses providers based on quality of care, outcomes, and cost, as opposed to a fee-for-service model that reimburses based on the volume of services delivered. Despite many experts and health care organizations agreeing that this volume-to-value transition is necessary and fundamental to doing business, a conceptual framework to guide health centers in steps to bring about this change has been lacking. To date, there has not been a clear, standardized, organizing model that federally qualified health centers (hereafter referred to as “health centers”) can use as an actionable pathway to overall systems change that advances value. Although other conceptual models exist for enhancing the care system in support of chronic disease management,4 patient-centered medical home,5 or systems improvement,6 these models do not explicitly address the four Quadruple Aim goals of improved health outcomes, improved patient and staff experience, and reduced costs (which the Value Transformation Framework [VTF] defines as “value”) and are not focused on the health center environment—primary care providers focused on caring for vulnerable populations. The need for a conceptual model that can readily be implemented by health centers operating in a complicated and dynamic environment amidst diverse and complex patient populations drove development of the “VTF” (Figure 1).7 This article describes the development of the VTF and defines the resulting conceptual model.
The National Association of Community Health Centers, Inc. (NACHC) is the national membership organization for health centers that meet the Health Center Program requirements set forth by the Health Resources and Services Administration (HRSA).8 NACHC works closely with health centers, primary care associations (PCAs), and health center–controlled networks (HCCNs) to support the nationwide delivery of high-quality primary care services to communities in need. PCAs are state or regional membership organizations that offer training and technical assistance to safety-net providers. HCCNs are groups of health centers working together to support and enhance the use of health information technology to improve access and quality, and lower costs. NACHC's Quality Center9 developed the VTF in response to the need articulated by the field for support in gathering, synthesizing, and translating the expansive body of evidence around systems' change in support of the transition from a volume-based to value-based model of care into action steps health centers can readily implement.
Health centers provide care to approximately 28 million patients at approximately 12,000 delivery sites across 1,400 organizations.8 Many health center patients have incomes below the Federal Poverty Level and face social and environmental risk factors that affect their health.10 Despite the complexity of serving high-risk patients with disproportionate burdens of disease, health centers consistently provide quality care that meets or exceeds the performance of private practice primary care offices,11 at a lower cost.12 It is estimated that health centers save the health care system $24 billion annually.12 Yet, health centers and their respective clinicians and staff—burdened with competing initiatives, rapidly changing technologies, and the demand for practice transformation—are experiencing increased burnout and decreased satisfaction.13–15 System transformation efforts can help address staff resistance and turnover but should be done with consideration for the true costs of transformation activities.16
Berwick et al17 first introduced the idea that high-value health care results from the interplay of linked goals. The Berwick team originally defined the “Triple Aim” as a set of three interdependent goals: improved population health, improved individual care experiences, and reduced costs. These factors are interrelated—changes in one affect all others. To build on this concept, Sikka et al18 incorporated the critical role of the workforce, thereby expanding the “Triple Aim” to the “Quadruple Aim.”18 And while early models of the Quadruple Aim reference provider or clinician experience, more recent versions, including the VTF, expand this view to “staff” experience—recognizing the need to consider the quality of work life for all who deliver care to patients.19 This is particularly true in health centers given their use of team-based models of care.
The transition from a volume-driven to value-driven model3 compels health centers to integrate the Quadruple Aim in their business models. Achieving all these goals simultaneously becomes an exercise of balance and a business imperative. Approaching the work of complex health center systems change in a practical way that advances value is the goal of the VTF.
In response to the complex and competing demands described by health center staff, NACHC's Quality Center developed the VTF (Figure 1)—defining “value” as the Quadruple Aim goals. The methods undertaken in building and refining the VTF involved a four-set process:
- Step 1: Environmental scan/literature review and design of the VTF conceptual model (2016).
- Step 2: Field testing of the VTF through application in a health center transformation project (2017–2018).
- Step 3: Organized call for feedback among a selected cohort of health center stakeholders (2018).
- Step 4: Engagement of the field in operational considerations and ongoing feedback (2019-ongoing).
Step 1: Environmental Scan/Literature Review and Design of the Value Transformation Framework Conceptual Model (2016)
Design work began with an environmental scan and literature review that consisted of a systematic, manual search of peer-reviewed literature and gray literature to identify the domains of “value” that would be relevant for health centers. A broad approach was taken, without placing parameters on publication years, using an iterative list of key word searches that included such initial terms as “health centers,” “value-based care,” “transformation,” “systems change,” and “quadruple aim”—that then led to secondary searches (e.g., population health, care teams, and leadership) as themes emerged from the primary searches. The Conceptual Framework for Planning and Improving Evidence-Based Practices developed by the Centers for Disease Control and Prevention's (CDC) Best Practices Workgroup guided selection and evaluation of best available practices.20 This group developed a working definition of best practices and a conceptual framework for creating a set of best practices. “Best practice” was defined as “a practice supported by a rigorous process of peer review and evaluation indicating effectiveness in improving health outcomes, generally demonstrated through systematic reviews.”20 The CDC framework considers evidence and/or best practices along two interrelated components: a combination of impact (effectiveness, reach, feasibility, sustainability, and transferability) and quality of evidence (with a range from weak to rigorous). The intersection of impact and evidence is viewed along a continuum of “emerging,” “promising,” “leading,” and “best practices.”20
From our initial review of more than 200 articles identified through the literature search, we distilled a set of themes that we call Change Areas. Change Areas include Improvement Strategy, Health Information Technology, Policy, Payment, Cost (originally combined with Payment and later separated out), Population Health Management, Patient-Centered Medical Home, Evidence-Based Care, Care Coordination and Care Management, Social Determinants of Health, Patients, Care Teams, Leadership, Workforce, and Partnerships (Figure 2). Change Areas, when acted upon, can contribute to health center advancement in the Quadruple Aim goals. Topics were selected as Change Areas if, according to CDC's conceptual framework, they encompassed actionable steps that ranked high along the impact and evidence scales and thus were “promising” (positive evidence but application may be subject to context), “leading” (peer-reviewed studies or published evaluations), or “best practices” (intervention evaluations or studies with evidence of impact).20 We synthesized the findings and themes that emerged from the environmental scan and formal literature review into the VTF conceptual model. The Change Areas were further grouped into three Domains: Infrastructure, Care Delivery, and People. Organization of the Changes Areas within three overarching Domains was performed to further bundle the complex and daunting tasks of systems change into manageable pathways for change. The resulting conceptual model then underwent a process of pilot testing and gathering input from the field.
Step 2: Field Testing of the Value Transformation Framework Using Application in a Health Center Transformation Project (2017–2018)
Field testing of the VTF took place in 2017–2018 through a CDC-funded 2-year Cancer Transformation Project focused on increasing rates of colorectal and cervical cancer screening rates. The aim was to increase screening rates through application of the VTF and a systems approach to change. This pilot test applied the VTF in a learning community model combined with evidence-based cancer screening interventions. The project was implemented at eight health center sites in two states (Georgia and Iowa). This testing engaged more than 40 health centers staff at all levels of the organization, from administrators and clinicians to frontline staff, in application of the conceptual model. The project involved nesting health centers' efforts at improving cancer screening rates within a larger VTF health systems change effort. The intent of the project was to influence clinical conditions and performance metrics, including colorectal and cervical cancer screening rates and Quadruple Aim goals, by providing pathways to modify health center Infrastructure, Care Delivery, and People systems. Minor refinements to the model, largely in fine tuning the definitions for each Change Area, were made as a result of the pilot.
Step 3: Organized Call for Feedback From Health Center Stakeholders (2018)
This round of feedback included a focused period of comment by approximately 18 health center, PCA, and HCCN representatives on the definitions and parameters of each of the Change Areas. Subject matter experts within NACHC and the Quality Center's Quality Improvement Advisory Board (a national cross-section of health center, PCA, and HCCN representatives charged with guiding the Quality Center's clinical and quality priorities) also contributed to this refinement. This resulted in some additional updates to the definitions of the Change Areas. No changes were made to the conceptual model itself.
Step 4: Engagement of the Field in Operational Considerations and Ongoing Feedback (2019—Ongoing)
NACHC's Quality Center continued to advance the VTF, introducing it to stakeholders beyond the health centers engaged in field testing and those who provided input on Change Area definitions. This included a presentation and opportunity for feedback at a national convening of health center leaders in early 2019 and a smaller focus group of primary care association staff working with member health centers to apply the model. This phase centered primarily around recommendations for application of the model by the field.
This iterative process of designing, testing, and translational refinement of the VTF engaged a wide audience of staff across health centers, PCAs, HCCNs, and NACHC. The VTF, conceptualized and designed in 2016 following an extensive review of the literature and environmental scan, has been further shaped through a multiyear process of field testing, stakeholder feedback, and subject matter expert review and comment. As this article reports on the conceptual development of the VTF and not its application, the conceptual development phase did not undergo Institutional Review Board review. Application of the model, reported elsewhere, underwent Institutional Review Board review and was deemed quality improvement and thus “nonjurisdiction.”
The author distilled evidence-based and promising practices to form the VTF in 2016 (Figure 1). The VTF model to advance the Quadruple Aim organizes the health center system into three Domains, each of which has five Change Areas that, when acted upon, can contribute to health center advancement toward achieving the Quadruple Aim (Figure 2). The three Domains include the following:
- Infrastructure: The components that build the foundation for delivering reliable, high-quality healthcare.
- Care Delivery: The processes and proven approaches used to provide care and services to individuals and target populations.
- People: The individuals who receive, provide, and lead care at the health center and partner organizations to support the goals of high-value care.
The 15 Change Areas are distinct components of change that should be targeted for transformation based on evidence-based research and best practices. Each Change Area includes well-defined yet flexible action steps for improvement. The VTF also includes Action Guides that take this one step further by offering concise, evidence-based, and logical step-by-step instructions that health centers can apply within a given Change Area to advance health center transformation toward the Quadruple Aim goals. An example of concrete and evidence-based steps that pertain to colorectal cancer screening includes updating and/or developing new clinical policies and protocols and standing orders for cancer screening; sharing performance data with provider and care teams; implementing automated reminders for cancer screening (to prompt providers); and reaching out to patients (reminding them of the need for cancer screening or to return a colorectal cancer screening stool-based test). Action Guides focus on topics such as risk stratification, care management, leadership, care teams, and patient engagement. Action steps within each guide are tailored to the specific topic area. The Patient Engagement Action Guide, for example, includes the following action steps: (1) identify a patient engagement lead; (2) establish patient engagement metrics; (3) use daily huddles to support patient engagement; (4) enhance patient communication skills; (5) provide a written care plan or visit summary; (6) use patient decisions aids; and (7) train staff in patient engagement. Action Guides are found at http://www.nachc.org/clinical-matters/value-transformation-framework/.
The resulting VTF was designed to offer manageable action steps a variety of staff can engage in, and contribute to, at different levels—directing change in multiple parts of the overall health care system simultaneously. Taken together, the actions of many staff across the Change Areas of the model can result in advancement of overall systems transformation toward value. The VTF model is designed to enable leadership within a health center to look at their organization as a system of distinct Change Areas that can be calibrated to improve overall value.
Results from field testing the VTF in the Cancer Transformation Project showed that within a cohort of health centers, on average, the overall percent of patients at target sites who received colorectal cancer screening, per Uniform Data System guidelines maintained by HRSA, increased over 13 percentage points in the first intervention year.21 Although additional analysis of the project data is currently underway, unadjusted overall rates for the panel of clinical measures tracked by the project: colorectal and cervical cancer screening, diabetes, hypertension, obesity, and depression, all improved. One modification to the Framework resulting from the field testing was the separation of “Cost” into a standalone Change Area rather than its previous inclusion as part of “Payment.” This was to make the important distinction between the areas of cost and payment, and to allow for fuller attention to the evidence base in each of these areas.
Steps 3 and 4 (an organized call for feedback and engagement of the field in operational considerations and ongoing feedback) served to fine tune the definitions and focus of each Change Area and provide recommendations for further application of the model in health centers. In early 2019, the VTF was deployed in a national cohort of health centers as part of the Elevate learning forum. Results of this initiative, with application of the VTF in 115 health centers and 17 PCAs/HCCNs across 19 states (AK, AZ, CT, GA, IA, IL, IN, KS, MA, MI, MN, NJ, NY, OH, PA, RI, SC, TN, and WI), will be available in 2020.
The balance between flexibility (to ensure ease of implementation) and fidelity/standardization (to aim for generalizability) of any model must be taken into account. The VTF offers a construct for approaching health center systems' change that can be applied across health centers nationally (fidelity) while allowing health centers latitude in how they deploy each Change Area (flexibility). The VTF lays out a path for health center systems transformation that allows for local implementation. Within the 15 Change Areas are recommended actions a health center can take specific to that part of the system but, how a health center takes the action, or in what ways it performs the action, is flexible. For example, the recommendation within the Evidence-Based Care action guide to implement a cancer screening clinical policy does not prescribe which clinical guidelines to follow, but it does offer recommendations around a leading national guideline (e.g., U.S. Preventive Services Task Force) and provides a sample clinical policy that could be adapted by a health center. Similarly, the model recommends implementation of standing orders for cancer screening but recognizes that implementation must consider local/state laws and licensure parameters and model any standing orders to fit local conditions. Sample standing orders are provided for adaptation by a health center, where appropriate.
That said, to understand the degree of the VTF's generalizability, the VTF needs to be applied and used in more settings. It will be important to observe the experiences of health centers that differ from one another in size, geography, and patient populations. In addition, each health center will apply the VTF in ways that match their unique organizational culture, quality improvement processes, and resources. This flexibility means that a custom-tailored method or approach used by a particular health center may not be generalizable to other health centers.
The Affordable Care Act (ACA), passed in 2010, aimed to resolve underlying problems in the way healthcare is delivered and paid for in the United States.22 The ACA focused on testing new delivery models and disseminating successful ones, encouraged a shift toward payment based on the value of care provided, and developed resources for systemwide improvement. Despite some progress in these goals, many agree that we are in the midst of a growing crisis of health care systems that requires a new definition of health as part of the transition to value-based solutions.23
The complex task of systems' change required to move health centers toward value-based models of care delivery led to the development of the VTF and its function as an organizing framework for this transition. When a structured, step-by-step process, as outlined by the VTF, is offered to health centers with operational Change Areas organized into clear Domains, improvements such as those seen in early pilot applications of the model may be possible.21
Future efforts to apply the VTF within additional health centers may shed added light on such issues as: the order or sequence of change on results, the areas of health center Infrastructure, Care Delivery, or People systems that are most amenable to change through the VTF model, and any differences in application based on the size or characteristics of the health center or patient populations served. Input from health centers on their experiences in applying the VTF will aid in understanding how other characteristics (e.g., degree of leadership support and openness to change) may affect how interventions are implemented and the degree to which the Quadruple Aim goals are achieved.
NACHC's Quality Center's VTF helps advance implementation science by providing a broad conceptual model with focused definitions and actionable steps. The VTF model can be applied as a powerful knowledge base of best practices across multiple areas of the health care system. The VTF specifies a list of Change Areas within interrelated Domains that can contribute to the Quadruple Aim. Furthermore, the VTF offers opportunities for new implementation science and research. Other theories that hypothesize on mechanisms of change or interactions within and across the Domains of the VTF can be developed and tested empirically.
The VTF framework was designed to support health centers in navigating change efforts toward value-based care. Although the intended audience of the VTF is federally qualified health centers, the steps and actions described in the VTF may also apply to other health care organizations and networks. If the VTF approach continues to demonstrate value, it can provide an actionable guide for systems change in advancing on the Quadruple Aim goals. The VTF is structured as a useful construct, yet it is sufficiently flexible and nimble to accommodate individual organizational experiences. Furthermore, the VTF serves as a powerful example of how a national association can add important evidence-informed and practical value to the field.
Cheryl Modica, PhD, MPH, BSN, is a Director at the Quality Center, National Association of Community Health Centers (NACHC, Bethesda, Maryland), and leads national collaborative efforts and strategies in support of improved patient and staff experience, improved outcomes, and reduced costs. She directs and strategically coordinates clinical quality improvement, performance measures and metrics, clinical decision support, and operational integration and transformation. She is responsible for building and expanding NACHC's Quality Center and leading clinical and quality innovation.
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