A Team Approach with the Advanced Preventive Care Model


Perspectives from Ken Coburn, MD, DrPH, FACP, Health Quality Partners

Health Quality Partners, based in Southeastern Pennsylvania, created the Advanced Preventive Care (APC) model for chronically ill older adults. This multi-faceted model uses specially trained community-based nurses to improve the overall quality of life and health outcomes of chronically ill older adults by preventing a wide range of risks to health that are not readily addressed by most systems of care.

The model harnesses a deep understanding of patients’ lived experiences, focusing on care coordination and personalized preventive interventions. Key to the approach is a continuous relationship between nurse and patient with frequent in-person contacts that provides a significant opportunity to proactively mitigate health risks. Health Quality Partners has been implementing and refining APC for 20 years and has helped other providers replicate and adapt the model and demonstrate ROI across different payment mechanisms. The Better Care Playbook recently spoke to Ken Coburn, MD, DrPH, FACP, CEO and Medical Director of Health Quality Partners to glean lessons for other organizations that may be interested in implementing complex care programs.

Q: What have you learned about implementing a successful complex care program?

Our model maximally leverages nurses’ backgrounds and capabilities to become excellent “preventionists,” by providing robust training, mentoring, and back-up support, along with a protocol-enhanced and data-driven approach to team performance. A successful complex care program requires an intentionally designed system grounded in patient-centered care and training focused on prevention and anticipation of complex needs for vulnerable populations.

Q: What obstacles will people face in implementing a complex care program?

The biggest obstacle is ensuring an upfront understanding from the field that we need to be patient in terms of the return on investment for a prevention-focused program. However, if committed to longitudinal care management and value-based care for the long-run, APC is a proven model that generates savings through sustainable improvements in health outcomes, not just better coding. There needs to be a funding source and system in place that recognizes that managing complex care takes time and creativity, but it can pay off. The other major obstacle is fixed notions about what does and does not work – being ruthlessly honest about what we know about other care delivery interventions or models in the field and being committed to rigorous ongoing analysis is the foundation of a scientific approach to this work.

Q: How did you make the case for this work with peers and/or executives?

We have a 13-year randomized control trial involving thousands of enrollees, which showed through patient outcomes that this works. Qualitative feedback studies have shown that patients reported feeling more engaged and that they have someone “in our corner.” Research has also shown that this model, for appropriately targeted populations, can lower net health care costs from 10 to 28 percent.

Q: What are you most proud of from your work?

APC saves lives, improves health outcomes, and reduces human suffering. Those are the reasons Health Quality Partners exists.