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Developed by Synergy 3C – The Clinical Consulting Cooperative, LLC, in collaboration with the University of Tennessee Health Science Center, Tennessee Rural Health Care

Copyright From Readiness to Risk: A Rural Value-Based Care Playbook Copyright © 2026 Synergy 3C – The Clinical Consulting Cooperative, LLC. All rights reserved. The Synergy 3C Way, including its proprietary methodologies, frameworks, graphics, worksheets, planning tools, and related content, is the intellectual property of Synergy 3C – The Clinical Consulting Cooperative, LLC. Use and distribution of this publication are subject to the Attribution and Use Statement contained herein.

Acknowledgements I am especially grateful to the Tennessee Rural Health Care Center of Excellence at the University of Tennessee Health Science Center for its collaboration and shared commitment to advancing practical solutions that improve the sustainability of rural healthcare. I also acknowledge the inﬂuence of my late father, Bill Brown, who was rural to his core and lived by pragmatic principles in all things. His “country boy philosophy” taught me the value of common sense and preparation, grounded in hard work and practical solutions. Those lessons are woven throughout the Synergy 3C Way. My sincere appreciation goes to the rural healthcare leaders and community partners who shared what works, what does not, and what still needs to change, and to the reviewers and contributors whose expertise and thoughtful feedback strengthened this work.

Project Contributors Lead Author Rebecca (Becki) Brown Baker, BSN, RN, BS Ed

Contributing Authors Michelle Mirkovic, PT, MHA Aaron Wells, PhD

Content Reviewers Robert Goldstein, MBA James Haynes, M.D., MBA Melissa Hutchison, MHA Sawan Kothari, MBBS

Disclaimer, Attribution and Use Statement Disclaimer This playbook provides strategic guidance and practical recommendations to support Value-Based Care leadership, organizational decision-making, and capability development. It is not intended to replace organization-specific legal, financial, accounting, reimbursement, regulatory, or clinical advice. Healthcare organizations operate within unique clinical, financial, operational, and regulatory environments. Apply the strategies, frameworks, principles, examples, and tools presented here within the context of your organization's circumstances and seek professional advice when appropriate.

Attribution and Use Statement From Readiness to Risk: A Rural Value-Based Care Playbook

A Practical Guide to Value-Based Care On-Ramps, Foundational Capabilities, and Organizational Sustainability

This publication contains proprietary Synergy 3C frameworks, methodologies, and tools and was developed in collaboration with the Tennessee Rural Health Care Center of Excellence at the University of Tennessee Health Science Center. Permission is granted to download, reproduce, and distribute this publication in its entirety for noncommercial educational, organizational planning, strategic planning, and internal healthcare improvement purposes, provided all attribution and copyright notices remain intact. No portion of this publication may be modiﬁed, excerpted, adapted, incorporated into derivative works, or used for commercial purposes without the prior written permission of Synergy 3C – The Clinical Consulting Cooperative, LLC. © 2026 Synergy 3C – The Clinical Consulting Cooperative, LLC. All rights reserved.

Table of Contents The Synergy 3C Way ....................................................................................................................................... 7 Executive Summary: Why Value-Based Care? Why THIS Playbook? .................................................................. 8 How to Use This Playbook ............................................................................................................................... 9 The right capabilities today create the opportunity for the right payment model tomorrow. .................................... 9 Using the Appendices ....................................................................................................................................... 9 Key Terms and Deﬁnitions ............................................................................................................................... 10 Part I: Understanding Value-Based Care ........................................................................................................ 12 Why This Playbook Exists ................................................................................................................................ 14 What Value-Based Care Means in Practice ....................................................................................................... 16 Common Myths and Misconceptions ............................................................................................................... 17 Part II: Assessing Readiness ......................................................................................................................... 19 Why Readiness Matters – Especially for Rural Healthcare .................................................................................. 21 The Readiness Domains .................................................................................................................................. 21 Domain 1: Leadership and Governance ........................................................................................................... 22 Domain 2: Clinical Readiness .......................................................................................................................... 23 Domain 3: Operational Readiness.................................................................................................................... 24 Domain 4: Data & Technology Readiness.......................................................................................................... 25 Domain 5: Financial Readiness........................................................................................................................ 26 Domain 6: Quality and Compliance Readiness ................................................................................................. 27 Part III: Selecting the Right Value-Based On-Ramp ......................................................................................... 29 Choosing the Right Starting Points ................................................................................................................... 31 Delivery Structures, Shared Services, and Payment Models ............................................................................... 34 Choosing the Right Value-Based Care On-Ramp ............................................................................................... 36 Part IV: Building Foundational Capabilities .................................................................................................... 39 Building Foundational Capabilities .................................................................................................................. 41 Summary ....................................................................................................................................................... 51 Part V: Pilot, Learn, Improve, and Progress .................................................................................................... 54 Don’t Wait. Start Building!................................................................................................................................ 56 Closing: From Playbook to Practice ............................................................................................................... 67 Selected References .................................................................................................................................... 69 For Further Reading ...................................................................................................................................... 69

Appendices ................................................................................................................................................. 70 Appendix 1: Organizational Capability Inventory & Readiness Assessment ......................................................... 71 Appendix 2: Collaborative Structure Selection Guide ........................................................................................ 80 Appendix 3: Foundational Capability Evaluation & Planning Tool ........................................................................ 83 Appendix 5: Risk Stratiﬁcation Worksheet......................................................................................................... 89 Appendix 6: Closed-Loop Referral Process Checklist & Best Practices ............................................................... 92 Appendix 7: Care Transition Mapping Tool ........................................................................................................ 94 Appendix 8: Workﬂow Mapping Template ......................................................................................................... 97 Appendix 9: Roles, Responsibilities & Accountability Template .........................................................................100 Appendix 10: Strategic Partnership & Shared Service Evaluation Tool ................................................................101 Appendix 11: Technology Inventory Worksheet ................................................................................................106 Appendix 12: Interoperability Planning Checklist .............................................................................................109 Appendix 13: Data Governance Checklist........................................................................................................111 Appendix 14: Value-Based Care Contract Evaluation Guide..............................................................................113 Appendix 15: Financial Modeling & ROI Worksheet ..........................................................................................116 Appendix 16: Core Value-Based Care Metrics Dashboard ................................................................................120 Appendix 17: Performance Improvement Drivers .............................................................................................122 Appendix 18: Performance Improvement Action Plan .......................................................................................125 Appendix 19: Quality Assurance / Performance Improvement Committee Template...........................................126 Appendix 20: Compliance Requirement Checklist ...........................................................................................128 Appendix 21: Organizational Destination Planning Worksheet...........................................................................130 Appendix 22: Leadership Alignment Discussion Guide .....................................................................................134 Appendix 23: Capability Prioritization Matrix ....................................................................................................137 Appendix 24: Strategic Partnership Planning Worksheet ...................................................................................138 Appendix 25: MVP Scope Planning Template ...................................................................................................141 Appendix 26: Vision and Direction Communication Planner .............................................................................143 Appendix 27: Minimum Viable Pilot (MVP) Planning Worksheet .........................................................................145 Appendix 28: MVP Action Plan ........................................................................................................................149 Appendix 29: MVP Evaluation & Lessons Learned ............................................................................................151 Appendix 30: MVP SWOT Template .................................................................................................................157 Appendix 31: Root Cause Analysis Worksheet .................................................................................................159 Appendix 32: Value-Based Care Roadmap ......................................................................................................161 Appendix 33: Are We Ready to Advance? Decision Tool ....................................................................................165

The Synergy 3C Way With nearly three decades of helping healthcare organizations navigate change, I have seen these principles guide the most successful transformations. They reﬂect how our team thinks, how we advise, and how we build sustainable Value-Based Care strategies and successful value-driven organizations. If this playbook challenges the way you think about Value-Based Care, it has accomplished exactly what I intended. Value-Based Care is so much more than another reimbursement program! It is an opportunity to redesign healthcare around what matters most: healthier patients, stronger organizations, happier clinicians, and more sustainable communities.

Becki Brown Baker, BSN, RN, BS Ed

Executive Summary: Why Value-Based Care? Why THIS Playbook? The writing is on the proverbial wall. Value-Based Care is no longer an emerging healthcare strategy. Payment models will continue to evolve, but the direction is clear. Healthcare organizations are already expected to deliver better outcomes while demonstrating quality and effective cost management. For rural healthcare organizations, the growing impetus toward Value-Based Care creates urgency—and opportunity. Organizations that start preparing now have more control over how they enter Value-Based Care and how quickly they progress. Those that wait may ﬁnd the decision being made for them, along with expectations they are not yet prepared to meet. Value-Based Care changes how an organization delivers care and measures performance. It requires clinical and ﬁnancial strategy to work together, supported by the people, processes, technology, and leadership needed to make the model work. Contracts demand performance. Capabilities determine whether you can deliver. We created From Readiness to Risk to give rural healthcare leaders a practical path forward. Before taking on greater accountability, leaders need to answer several critical questions: • • • • •

Where are we now? What are we already doing well? What must we strengthen? Which Value-Based Care opportunities make sense for us? What should we do next?

The goal is deliberate progression. Build what matters. Make sure it works. Learn from it. Then decide what comes next. You do not have to build everything at once, but you do have to be ready for whatever Value-Based Care model you take on.

The objective is not to participate in Value-Based Care. The objective is to succeed in it. And success starts with YOU.

How to Use This Playbook Intended Audiences The playbook was developed for leaders of rural healthcare organizations, including • Rural physician practices • Rural Health Clinics (RHCs) • Federally Qualiﬁed Health Centers (FQHCs) • Critical Access Hospitals (CAHs) • Community Hospitals

What This Playbook Is A practical guide for assessing readiness, building critical capabilities, and making informed decisions about entering, advancing, and succeeding in Value-Based Care.

How This Playbook Is Organized This playbook is organized around ﬁve key questions:

Part

Question Answered

Part I

What does Value-Based Care mean for rural healthcare, and what options are available to us?

Part II

How ready are we, and which capabilities matter most?

Part III

Which Value-Based Care pathway best ﬁts our readiness and goals?

Part IV

What must be in place before we move forward?

Part V

How do we pilot, learn, improve, and build a sustainable Value-Based Care roadmap?

The right capabilities today create the opportunity for the right payment model tomorrow. Using the Appendices The appendices at the end of the playbook contain the worksheets, templates, assessments, and planning tools referenced throughout the playbook.

Key Terms and Definitions Attribution The process of assigning patients to a provider, practice, or organization for purposes of measuring quality, outcomes, and financial performance. Attribution may occur at different levels, including from a payer to an organization and within an organization to an individual provider or care team. Blended Case Rate A payment model that combines multiple services or activities into a single predetermined payment for managing a patient or condition. Bundled Payment A single payment covering all or a portion of the services associated with a defined episode of care. Care Coordination The deliberate organization of patient care activities among providers, caregivers, and services to improve outcomes and reduce fragmentation. Fee-for-Service (FFS) A traditional reimbursement model in which providers are paid for each service delivered. Fee-for-Service Plus A reimbursement arrangement that maintains Fee-for-Service payments while adding quality incentives, care management payments, or other Value-Based Care components. Global Risk A payment arrangement in which an organization assumes responsibility for the total cost and quality of care for a defined population. Longitudinal Patient Management The continuous management of patients across time, including the periods between visits, through proactive outreach, monitoring, care coordination, and intervention. Minimum Viable Pilot Throughout this playbook, MVP refers to a Minimum Viable Pilot, not a Minimum Viable Product. A deliberately scoped pilot designed with the minimum capabilities, workflows, resources, and measures needed to meaningfully test a Value-Based Care model, evaluate performance, and generate actionable learning before expansion. Patient Journey Mapping The process of identifying how patients move through a healthcare organization, including key touchpoints, handoffs, transitions, and areas where patients may fall through the cracks. Per Member Per Month (PMPM) A fixed payment made each month for each attributed member or patient to support specific services, care management activities, or population health efforts. Pilot A limited implementation used to test a care model, workflow, program, or Value-Based Care strategy before broader implementation or expansion See also: Minimum Viable Pilot Population Health The systematic management of health outcomes, quality, utilization, and cost across a defined patient population. Quality Measures Standardized metrics used to evaluate clinical performance, patient outcomes, patient experience, access and other

dimensions of care quality. Examples include measures used in HEDIS, MIPS, Medicare Stars and CAHPS/HCAHPS programs. Risk Stratification The process of categorizing patients according to their likelihood of experiencing adverse outcomes, high utilization, or increased healthcare costs. Shared Savings A payment arrangement in which providers generate share savings through improved quality, reduced costs, or both when predefined performance targets are achieved. Shared Services Operational, clinical, or administrative capabilities that are provided across multiple organizations rather than developed independently by each organization. Strategic Partner An external organization that provides expertise, services, technology, or capabilities that support Value-Based Care objectives. Total Cost of Care The total healthcare spending incurred by a defined patient population across all settings and services during a specified period. Value-Based Care (VBC) A healthcare delivery and reimbursement approach that aligns payment with quality, outcomes, patient experience, and responsible management of healthcare resources. Value-Based Payment Model A reimbursement structure that incorporates financial incentives tied to quality, outcomes, cost management, or other performance measures. Value-Driven Organization An organization that intentionally aligns and aligns clinical care, operations, technology, quality, and financial strategies around improving patient outcomes while responsibly managing healthcare resources. Variance The difference between expected and actual performance that can affect clinical outcomes and financial results. Variance is best controlled by an aligned clinical and operational model.

Part I:

Understanding Value-Based Care What does Value-Based Care mean in rural healthcare terms, and what options are available to organizations like ours?

Challenge: Think Differently

PART I Objectives Upon completion of Part I, you will be able to 1. Deﬁne Value-Based Care as a care delivery model 2. Differentiate Value-Based Care from Value-Based Payment 3. Describe the characteristics of a value-driven healthcare organization 4. Differentiate common Value-Based Care myths from operational realities 5. Explain the role of organizational readiness in Value-Based Care participation

Why This Playbook Exists Driving Principle: The best Value-Based Care on-ramp is the one that aligns with an organization's capabilities, resources, and long-term sustainability goals. Regardless of where an organization is in its Value-Based Care journey, the practical questions tend to be remarkably consistent (you spoke, we listened): •

What is Value-Based Care, and what does it mean for an organization like ours?

•

Are we already doing some of this today?

•

What must be in place before we move forward?

•

Do we have to assume ﬁnancial risk?

•

How do we know we’re ready for the next step?

•

What should we start?

•

What is a right path forward for our organization?

This playbook was developed to answer those questions. Rather than prescribing a single path, it provides a practical framework for evaluating opportunities, assessing readiness, and identifying the right path forward based on each organization's capabilities, goals, and resources. Many Value-Based Care resources explain WHAT successful organizations do. This playbook focuses on something different. Our goal is to help you determine what your organization should do next.

Rather than assuming every organization is ready for the same strategies, the playbook helps you identify the capabilities to build, the opportunities that ﬁt, and the practical path forward based on where you are today.

The playbook answers those questions through three lenses: Lens

Driving Question

On-Ramps

Which Value-Based Care opportunity best ﬁts our organization today?

Capabilities

What must be in place, and when, for us to succeed?

Progression

What is the appropriate next step?

Leadership Commitment – the Absolute Nonnegotiable Every recommendation in this playbook assumes active leadership commitment. Leadership's role in successful Value-Based Care transformation is discussed in Part IV.

80/20 Rule Organizations do not need every Value-Based Care capability fully developed before making meaningful progress. The 80/20 Rule focuses attention on the relatively small number of capabilities that will drive the greatest impact on successful implementation and performance. Prioritize and strengthen those capabilities ﬁrst. What matters most will vary based on an organization's goals, patient population, resources, and Value-Based Care pathway.

Readiness Before Risk Many rural organizations already coordinate care, manage chronic conditions, close care gaps, address barriers, and support patients between visits. The question is whether those activities are intentional, reliable, measurable, and sustainable. Build capabilities before pursuing greater accountability. Start small. Miss small. Learn great lessons.

✓KEY POINT

Build capabilities before pursuing greater accountability. Start small. Miss small. Learn great lessons.

Key Value-Based Care terminology used throughout this playbook is deﬁned in the Key Terms and Deﬁnitions section located in How to Use This Playbook.

What Value-Based Care Means in Practice Driving Principle: Value-Based Care begins with how care is delivered. Payment models create ﬁnancial accountability for the results. Value-Based Care aligns care delivery and reimbursement around better outcomes, quality, patient experience, provider satisfaction, and responsible use of healthcare resources. In practice, organizations work to • • • • • • • •

Identify patient needs and risks early Intervene before manageable problems become crises Coordinate care across providers and settings Support patients longitudinally, including between visits Close care gaps and referral loop Manage care transitions Address barriers to needed care Reduce avoidable utilization and improve outcomes (e.g. ED, Inpatient, specialists, etc.)

Many rural healthcare organizations are already performing some of these activities today, whether they consider themselves Value-Based Care organizations or not.

Fee-for-Service: The Foundation and Fee-for-Service Plus: The On-Ramp Fee-for-Service remains the reimbursement foundation for many rural healthcare organizations. It pays for visits, tests, procedures, and treatments but does not fully support the outreach, care navigation, care coordination, and longitudinal management needed to improve population health. Many organizations begin their Value-Based Care journey with Fee-for-Service Plus. This approach preserves traditional reimbursement while adding payments or incentives tied to quality, care management, patient engagement, or performance. Examples include • Quality incentive programs • Care management payments • Chronic Care Management (CCM) • Transitional Care Management (TCM) • Remote Patient Monitoring (RPM) • Performance-based bonuses

• •

Medicare Advantage & Medicaid Managed Care incentive programs Select shared savings arrangements that allow organizations to build Value-Based capabilities while continuing to operate primarily within a Fee-for-Service reimbursement structure

WORD TO THE WISE

Fee-for-Service Plus can be a practical, lower-risk Value-Based Care on-ramp because it allows organizations to build and test new capabilities while preserving the stability of traditional reimbursement.

What Makes an Organization Value-Driven? A contract does not make an organization value-driven. A value-driven organization intentionally aligns its clinical care, workﬂows, staffing, technology, data, quality activities, and accountability to improve outcomes across the patient journey. That responsibility extends beyond individual visits to include what happens between visits and across care transitions. Sustainable Value-Based Care occurs when payment arrangements support, rather than deﬁne, the organization’s care delivery model.

BEST PRACTICE

Build the capabilities required to deliver value before pursuing contracts that reward value.

WORD OF CAUTION

Contracts expose weak workﬂows, unclear ownership, fragmented communication, and limited data visibility. Entering an agreement before critical capabilities are reliable creates operational strain, provider frustration, disappointing performance, and avoidable ﬁnancial exposure.

Common Myths and Misconceptions Driving Principle: Value-Based Care can be pursued through many payer relationships and payment arrangements. Myth / Misconception Participation in Value-Based Care requires a CMS model. Participation in Value-Based Care requires an ACO. Value-Based Care requires downside ﬁnancial risk. Small rural organizations cannot succeed. Every capability must be built internally. Technology alone creates Value-Based Care success. Signing a Value-Based Care contract is the key to transformation. Every organization should progress to advanced risk.

Reality CMS models are only one pathway into Value-Based Care. Many organizations participate successfully without joining or creating an ACO. Many arrangements begin with incentives, care management payments, or shared savings without downside risk. Readiness depends more on reliable capabilities and appropriate alignment than organizational size. Strategic partnerships and shared services can ﬁll capability gaps. Technology supports the care model, workﬂows, decisions, and reporting required for success. Contracts demand performance. Capabilities determine whether you can deliver. The right level of accountability depends on organizational readiness and demonstrated performance.

WORD TO THE WISE Being asked to enter a Value-Based Care arrangement does not mean you should. Make sure you can perform BEFORE you sign

End Part I

Start Small. Miss small. Learn BIG!

Part II:

Assessing Readiness How do we know if we are ready, and which capabilities matter most?

Challenge: Know Yourself

PART II Objectives Upon completion of Part II, you will be able to 1. Assess your organization’s readiness across the six foundational ValueBased Care domains 2. Inventory existing capabilities and identify readiness gaps that require attention 3. Prioritize capability development based on organizational needs, strategic goals, and the Value-Based Care opportunity being considered 4. Determine organizational readiness before pursuing a Value-Based Care payment opportunity 5. Complete the Organizational Capability Inventory & Readiness Assessment in Appendix 1 to inform pathway selection

Why Readiness Matters – Especially for Rural Healthcare Driving Principle: Readiness measures the ﬁt between organizational capabilities, rural realities, and the Value-Based Care opportunity being considered. Rural healthcare organizations should assess readiness against their own operating realities rather than the infrastructure of larger health systems. Workforce limitations, geography, ﬁnancial constraints, and access challenges affect what can reasonably be built and sustained. At the same time, trusted patient relationships, community connections, local knowledge, and experience coordinating care with limited resources can provide a strong foundation for Value-Based Care. Readiness means knowing what the opportunity requires, what your organization can reliably deliver today, and where capability gaps must be addressed.

BEST PRACTICE Build what creates strategic value. Partner or use shared services when they provide the stronger, more sustainable solution. 0

WORD OF CAUTION

Do not adopt infrastructure simply because larger organizations use it. Every investment should solve a deﬁned need and support your Value-Based Care strategy. The readiness domains that follow help organizations inventory existing capabilities, identify gaps, and determine which Value-Based Care opportunities best align with their current level of readiness.

The Readiness Domains Driving Principle: Successful Value-Based Care organizations build capabilities intentionally rather than attempting to build everything at once. The readiness domains provide a structured way to assess the capabilities needed to support Value-Based Care and identify areas that require strengthening. Use Appendix 1: Organizational Capability Inventory & Readiness Assessment as you work through each domain.

Domain 1: Leadership and Governance Core Question Do our leaders have the alignment, governance, and accountability needed to lead and sustain Value-Based Care transformation?

What Good Looks Like Organizations demonstrating Leadership & Governance Readiness can consistently: • Articulate and communicate a clear vision for Value-Based Care. • Align leadership around organizational priorities, goals, and expected outcomes. • Make timely decisions that support organizational priorities. • Assign clear ownership, decision authority, and accountability. • Allocate resources according to strategic priorities. • Monitor organizational performance and adjust strategy when needed. • Lead organizational change with consistent communication and visible executive commitment.

Common Readiness Gaps • • • • • • •

Leaders hold different expectations or deﬁnitions of success. Competing priorities delay or undermine implementation. Ownership and decision authority are unclear. Executive engagement diminishes after implementation begins. Short-term operational pressures routinely override strategic priorities. Communication is inconsistent across leadership, departments, or teams. Organizational change lacks visible leadership support or shared purpose.

BEST PRACTICE Establish a multidisciplinary Value-Based Care leadership structure that routinely reviews performance, aligns priorities, removes barriers, and holds the organization accountable for execution.

WORD OF CAUTION Leadership alignment precedes transformation.

Self-Assessment Based on this domain, how would you rate your organization's current Leadership & Governance Readiness?

Emerging

Leadership alignment, governance, and accountability for VBC are not yet established.

Developing

Leadership supports VBC, but alignment, governance, or accountability is inconsistent.

Established

Leadership is aligned, with clear governance, decision authority, and accountability.

Advanced

Leadership and governance drive strategy, performance, accountability, and continuous improvement

Domain 2: Clinical Readiness Core Question Can we consistently deliver, longitudinal, patient-centered care?

What Good Looks Like Organizations demonstrating clinical readiness can consistently: • Anticipate patient needs and proactively manage risk. • Identify changes in condition and intervene early. • Coordinate care across providers and settings. • Maintain meaningful patient engagement between visits. • Deliver longitudinal care beyond episodic encounters. • Monitor patient outcomes and use performance data to improve care.

Common Readiness Gaps • • • • •

Signiﬁcant variation in care delivery across providers. Reactive care centered on episodic encounters. Limited ability to identify and proactively manage higher-risk patients. Patients falling through the cracks during referrals or transitions of care. Unclear or inconsistent accountability for care coordination and navigation.

•

Clinical performance data that is incomplete, delayed, or not routinely used to improve care

BEST PRACTICE Design clinical workﬂows around the patient journey. Identify where patients experience gaps, delays, handoff failures, or variation, then build the workﬂows and accountability needed to close those cracks.

WORD TO THE WISE Do not confuse individual clinical excellence with organizational clinical readiness. Outstanding clinicians working within inconsistent workﬂows rarely produce consistent organizational outcomes. Value-Based Care rewards reliable systems, not isolated acts of excellence.

Self-Assessment Based on this domain, how would you rate your organization’s current Clinical Readiness? Emerging

Signiﬁcant capability development needed before implementation.

Developing

Foundational capabilities exist but require strengthening

Established

Core capabilities are in place and functioning consistently.

Advanced

Capabilities are well integrated, measured, and continuously improved.

Domain 3: Operational Readiness Core Question Do our workﬂows, resources, partnerships, and accountability structures support proactive, longitudinal patient management?

What Good Looks Like Organizations demonstrating operational readiness can consistently: • • • • • • •

Execute standardized clinical and operational workflows. Define clear roles, responsibilities, and accountability. Coordinate work across teams with reliable handoffs. Maintain closed-loop referral and care transition processes. Support proactive outreach, monitoring, and intervention between visits. Measure operational performance and improve workflows when needed. Map how patients move through the organization and identify where they fall through the cracks.

Common Readiness Gaps • • • • • •

Heavy reliance on individual staff members rather than standardized processes. Unclear ownership or accountability for key workflows. Inconsistent handoffs between clinical and administrative teams. Referral, transition, or follow-up processes that allow patients to fall through the cracks. Workflows that depend on manual workarounds or unnecessary duplication. Limited visibility into operational performance or workflow failures.

BEST PRACTICE Map the patient journey to identify workflow breakdowns, communication failures, referral gaps, delays in care, and opportunities to improve continuity. Then define the workflows, ownership, and accountability needed to close those cracks.

WORD TO THE WISE Memorializing inefficient workarounds often creates operational barriers that become increasingly difficult to overcome as Value-Based Care responsibilities expand.

Self-Assessment Based on this domain, how would you rate your organization’s current Operational Readiness? Emerging

Signiﬁcant capability development needed before implementation.

Developing

Foundational capabilities exist but require strengthening

Established

Core capabilities are in place and functioning consistently.

Advanced

Capabilities are well integrated, measured, and continuously improved.

Domain 4: Data & Technology Readiness Core Question Can we identify, measure, monitor, and report performance?

What Good Looks Like Organizations demonstrating Data & Technology Readiness can consistently: • Access reliable and timely clinical, quality, utilization, and financial data. • Identify patient populations requiring intervention and stratify them by risk and need. • Monitor performance using meaningful measures and dashboards. • Use data to guide clinical, operational, and financial decisions. • Exchange information across providers, care settings, and strategic partners when needed. • Use technology that supports workflows without creating unnecessary administrative burden.

Common Readiness Gaps • • • • • • •

Data resides across multiple systems with limited interoperability. Performance reporting depends heavily on manual data collection or validation. Incomplete or inconsistent documentation compromises measurement and reimbursement. Limited visibility into patient populations, care gaps, or utilization patterns. Reports describe what happened but provide little actionable insight. Technology creates additional work or disrupts clinical and operational workﬂows. Existing technology capabilities are underutilized, or workﬂows are built around technology.

BEST PRACTICE Develop care models that support proactive outreach, risk-based interventions, care coordination, patient navigation, and longitudinal patient management.

WORD TO THE WISE Organizations that focus primarily on episodic encounters often struggle to achieve the outcomes required for Value-Based Care success.

Self-Assessment Based on this domain, how would you rate your organization’s current Data & Technology Readiness?

Emerging

Signiﬁcant capability development needed before implementation.

Developing

Foundational capabilities exist but require strengthening

Established

Core capabilities are in place and functioning consistently.

Advanced

Capabilities are well integrated, measured, and continuously improved.

Related Tool: Appendix 1: Organizational Capability Inventory & Readiness Assessment

Domain 5: Financial Readiness Core Question Can we evaluate, support, and manage Value-Based Care payment arrangements?

What Good Looks Like Organizations demonstrating Financial Readiness can consistently: • Evaluate Outcome-Aligned Payment models for their financial structure, performance requirements, and level of financial accountability. • Connect clinical and operational performance to financial performance. • Evaluate the financial implications of a payment opportunity before entering an agreement. • Monitor quality, utilization, and financial performance. • Identify key cost and utilization drivers. • Align payment opportunities with organizational capabilities, resources, and goals.

Common Readiness Gaps • • • • • • •

Limited understanding of Outcome-Aligned Payment models and financial risk. Financial strategy developed independently of clinical strategy. Limited ability to measure the financial impact of clinical or operational performance. Poor visibility into cost drivers, utilization patterns, or contract performance. Pursuit of payment opportunities that exceed current organizational capabilities. Limited access to financial modeling, actuarial expertise, or contract evaluation resources. Assumption that greater financial risk automatically creates greater financial opportunity.

BEST PRACTICE Evaluate payment opportunities against your current capabilities and ability to reliably perform. Build experience and strengthen performance before assuming greater ﬁnancial accountability.

WORD TO THE WISE The best payment opportunity is not necessarily the one with the greatest ﬁnancial upside. It is the one your organization is prepared to execute successfully.

Self-Assessment Based on this domain, how would you rate your organization’s current Financial Readiness? Emerging Signiﬁcant capability development needed before implementation.

Developing Foundational capabilities exist but require strengthening

Established Core capabilities are in place and functioning consistently.

Advanced Capabilities are well integrated, measured, and continuously improved.

Domain 6: Quality and Compliance Readiness Core Question Can we reliably meet, measure, and demonstrate the quality and compliance requirements of our ValueBased Care arrangements?

What Good Looks Like Organizations demonstrating Quality and Compliance Readiness can consistently • Identify applicable quality, regulatory, contractual, and reporting requirements. • Translate requirements into workﬂows with clear ownership and accountability. • Capture and validate data needed to measure and report performance. • Monitor quality, outcomes, and compliance performance and address identiﬁed gaps. • Maintain documentation that supports care delivery, reporting, and reimbursement.

Common Readiness Gaps • • • • •

Quality and compliance requirements are not consistently integrated into clinical and operational workﬂows. Ownership and accountability are unclear. Documentation or data does not reliably support performance measurement, reporting, or reimbursement. Performance gaps are identiﬁed too late to intervene effectively. Corrective actions are inconsistently implemented or monitored.

BEST PRACTICE

WORD TO THE WISE

Build quality and compliance requirements into the workﬂows where care is delivered. Assign ownership, monitor performance routinely, and address gaps before they affect outcomes, reimbursement, or contractual performance.

Self-Assessment Based on this domain, how would you rate your organization’s current Quality & Compliance?

Emerging

Requirements, ownership, and monitoring processes are not consistently deﬁned.

Developing

Core processes exist, but execution, documentation, or monitoring remains inconsistent.

Established

Requirements are embedded in workﬂows, with clear accountability and reliable monitoring.

Advanced

Quality and compliance performance is integrated, routinely evaluated, and continuously improved.

Related Tool: Appendix 1: Organizational Capability Inventory & Readiness Assessment

End Part II

Don’t let desire outrun readiness. Prepare. Then choose wisely.

Part III:

Selecting the Right Value-Based OnRamp Which Value-Based Care pathway is the best ﬁt for our organization’s current capabilities, readiness, and goals?

Challenge: Choose Wisely

PART III Objectives Upon completion of Part III, you will be able to 1. Compare common Value-Based Care payment pathways based on organizational readiness, capabilities, and strategic goals 2. Differentiate payment models from collaborative delivery structures and shared service arrangements 3. Evaluate direct payer contracting and participation in a collaborative delivery organization to select the approach that best aligns with your organization’s current capabilities and strategic goals 4. Evaluate a specific Outcome-Aligned Payment opportunity for strategic, operational, financial, and performance fit 5. Select a Value-Based Care on-ramp that aligns accountability with your organization’s current capabilities and readiness

Choosing the Right Starting Points Your readiness assessment establishes where your organization is today. Use those ﬁndings to identify the Value-Based Care pathway your organization is prepared to pursue successfully.

**Complete Appendix 1 before proceeding to Part III** Driving Principle: Organizational readiness determines the right Value-Based Care pathway.

BEST PRACTICE

Organizations do not need every capability fully developed before beginning their Value-Based Care journey. They do need the foundational capabilities required for the pathway they choose. Remaining capabilities can be developed as organizational experience and performance mature.

WORD TO THE WISE

Choose the pathway you are prepared to execute successfully today while intentionally building for tomorrow.

Evaluating Your Options Value-Based Care pathways generally progress with increasing organizational capability, accountability, and ﬁnancial risk. Use this progression as a decision-making framework, not just a prescribed sequence.

Common Value-Based Care Payment Pathways

Note: For review, refer to the Key Terms and Deﬁnitions section at the beginning of the Playbook. Payment Architecture

Common Examples

Fee-for-Service (Baseline)

Traditional Medicare; Commercial Fee-forService

Common Value-Added Foundational Capabilities

Services generally limited to reimbursable patient encounters.

Your Organization Should Be Able To

Deliver high-quality care within a traditional volumebased reimbursement model while establishing the foundational workﬂows needed to support future Value-Based Care activities.

Payment Architecture

Common Examples

Fee-for-Service Plus

Quality incentive programs; Comprehensive Primary Care Plus (CPC+); PMPM payments; care coordination payments; commercial pay-forperformance arrangements/incentives

Shared Savings

Commercial shared savings contracts; MSSP Basic Track

Blended Payment Models

PMPM + Shared Savings; PMPM + Quality Incentives; other blended commercial arrangements

Common Value-Added Foundational Capabilities

- Preventive care - Quality measurement & reporting - Care coordination/navigation - Referral management - Chronic disease management - Transitional Care Management - Patient outreach/engagement - Patient education - Longitudinal patient management - SDOH interventions - Data and Reporting - Performance improvement All Fee-for-Service Plus capabilities plus - Population health management - Proactive patient outreach/ engagement - Utilization management - Performance analytics - Cost management - Continuous quality improvement - Financial performance monitoring -

Preventive care Longitudinal patient management Risk stratiﬁcation Proactive outreach Care coordination /navigation Advanced analytics Quality improvement Financial performance monitoring Coordinated team-based care

Your Organization Should Be Able To

Integrate value-added services into existing feefor-service workflows while consistently measuring, documenting, and improving performance for a defined patient population with specific inclusion, exclusion, and carve-out criteria.

Improve quality while reducing avoidable utilization and total cost of care across a contractually deﬁned patient population.

Manage prospective payments together with performance-based incentives while improving quality, patient outcomes, and ﬁnancial performance for a deﬁned patient population.

Payment Architecture

Common Examples

Episode-Based Payment

Bundled Payments

Case-Based Payment

Blended Case Rates

PopulationBased Payment

Prospective population payment models

Advanced Risk

Capitation; Global Budget; Full-risk population contracts

Common Value-Added Foundational Capabilities

Preventive care Standardized care pathways Episode management Multidisciplinary care coordination - Post-acute care management - Quality monitoring - Episode analytics. - Standardized clinical workflows - Coordinated service delivery - Quality monitoring - Cost management - Performance reporting - Comprehensive population health management - Longitudinal patient management - Preventive care - Risk stratification - Analytics - Quality improvement - Network management - Proactive intervention All population health capabilities plus - Advanced financial management - Actuarial analysis - Network optimization - Utilization management - Contract performance management - Enterprise risk management

Your Organization Should Be Able To

Coordinate care across an entire episode while consistently managing quality, patient outcomes, and total episode cost.

Deliver a deﬁned package of services efficiently and consistently within a predetermined payment amount. Proactively manage the quality, outcomes, utilization, and total cost of care for an attributed patient population.

Integrate clinical, operational, ﬁnancial, and data capabilities while assuming signiﬁcant accountability for quality, outcomes, and total cost of care for an attributed patient population.

Notes Fee-for-Service: included as a reference point because it remains the foundation for many rural healthcare organizations and often provides the operational base from which Value-Based Care evolves. Terminology: This playbook uses the more recent term, Outcome-Aligned Payment (OAP), to describe payment models that align reimbursement with quality, outcomes, patient experience, and responsible resource stewardship. Alternative Payment Model (APM) is used interchangeably when appropriate.

Delivery Structures, Shared Services, and Payment Models Driving Principle: Delivery structures organize how care and supporting services are delivered. Shared services allow organizations to access capabilities collectively or externally. Payment models determine how organizations are reimbursed. Why This Matters Organizations can pursue Value-Based Care independently, through shared service arrangements, or through collaborative structures such as an IPA, PHO, CIN, or ACO. The appropriate structure should support the organization's strategy, capabilities, and Value-Based Care goals.

Common Delivery Structures Delivery Structure

Primary Purpose

Shared Capability Support

Patient Attribution Required

Independent Practice

Delivers care independently while maintaining full organizational autonomy.

Limited

Independent Practice Association (IPA)

Allows independent practices to collaborate around contracting, selected services, and operational efficiencies while maintaining independence.

Limited to Moderate

Physician Hospital Aligns physicians and hospitals to improve coordination, Organization (PHO) quality, and contracting opportunities.

Moderate

Clinically integrates independent organizations through shared governance, quality improvement, data, care Clinically coordination, analytics, technology, education, and other Integrated Network shared services. Depending on its purpose and (CIN) governance, a CIN may also participate in Value-Based Care contracts on behalf of its members.

Extensive

Accountable Care Organization (ACO)

Moderate to Extensive

YES

Coordinates care for an attributed patient population and manages performance under Value-Based Care contracts.

Note: These structures are not mutually exclusive. Larger healthcare organizations or networks may use multiple structures simultaneously, including an IPA and an ACO operating as distinct but affiliated structures.

When Does a Collaborative Delivery Structure Make Sense? Joining or creating an IPA, PHO, CIN, or ACO is a strategic decision. A collaborative structure may provide access to shared capabilities, infrastructure, contracting opportunities, or scale that would be difficult to achieve independently. These structures may also require greater organizational readiness, ﬁnancial stability, reporting capability, or patient volume. Participation requirements vary by organization. © 2026 Synergy 3C – The Clinical Consulting Cooperative, LLC. All Rights Reserved.

Collaborative delivery structures should be viewed as strategic opportunities to grow toward, not as prerequisites for beginning your Value-Based Care journey.

WORD TO THE WISE Before joining a collaborative delivery structure, know what you are signing up for. Know what will be provided to you and what will be expected of you. Participation requirements can vary considerably across organizations.

Direct Payer Contracting Direct payer contracting can provide a practical Value-Based Care on-ramp for even the smallest rural healthcare organizations. Agreements may be established with commercial payers, Medicare Advantage plans, Medicaid managed care organizations, or other payer partners. Start with one payer, one deﬁned patient population, and a limited-scope Minimum Viable Pilot (MVP). Use the pilot to test workﬂows, measure performance, and strengthen capabilities before expanding.

BEST PRACTICE Start small enough to learn and improve before you scale.

WORD TO THE WISE Your ﬁrst Value-Based Care contract and pilot sets a learning curve. Leave yourself room to learn before the stakes get higher.

Related Tools Appendix 2: Collaborative Structure Selection Guide Appendix 3: Foundational Capability Evaluation & Planning Tool

Should We Join an Existing Collaborative Delivery Organization? Before joining an ACO, CIN, IPA, PHO, or other collaborative structure, evaluate whether the organization supports your strategy and provides meaningful value for your participation.

Questions to Ask: ☐ Does participation align with our strategic goals and populations we serve? ☐ Have we evaluated whether participation offers greater value than other Value-Based Care opportunities available to us? ☐ What capabilities, infrastructure, and services will the organization provide us? ☐ What level of dedicated, ongoing support will we receive to help us succeed throughout the relationship? ☐ What clinical, operational, quality, data, ﬁnancial, and participation requirements will be expected of us?

☐ What are the financial obligations, payment arrangements, and potential financial risks associated with participation? ☐ How will we participate in governance and decisions that affect our organization? ☐ Does the value we expect to receive justify the requirements and obligations of participation? ☐ If we are considering multiple organizations, how do they compare in services, support, payment opportunities, shared savings, initiatives, participation requirements, and financial risk?

WORD TO THE WISE Compare more than the money. The strongest partner may not offer the greatest ﬁnancial opportunity upfront. Consider the support, capabilities, resources, and long-term partnership each organization provides to help you perform successfully over time.

Choosing the Right Value-Based Care On-Ramp Driving Principle: The right on-ramp aligns the level of accountability with the capabilities your organization can reliably execute today. Choosing an on-ramp requires bringing together what you now know about your organization and the opportunities available to you. Use your readiness ﬁndings to narrow the options, then evaluate the payment arrangement and delivery structure that best align with your current capabilities and strategic goals.

Choose Your On-Ramp Before moving forward, conﬁrm the following: ☐

Readiness:

Our foundational capabilities support the level of accountability being considered.

☐

Strategic Fit:

The pathway supports our organizational goals and the population we intend to serve.

☐

Payment Fit:

We understand how payment is earned, how performance is measured, and the ﬁnancial accountability involved.

☐

Delivery Fit:

We have identiﬁed the delivery structure that best supports successful performance.

☐

Capability Gaps:

Any remaining gaps can be addressed before they jeopardize performance (think the “20” of the 80/20 rule)

BEST PRACTICE Choose the lowest level of accountability that allows you to build meaningful experience and demonstrate performance. Progress as your capabilities and results support the next step.

WORD TO THE WISE More ﬁnancial upside usually comes with more accountability. Make sure your organization is prepared for both.

Related Tools Appendix 1: Organizational Capability Inventory & Readiness Assessment Appendix 2: Collaborative Structure Selection Guide Appendix 3: Foundational Capability Evaluation & Planning Tool

With your on-ramp identiﬁed, Part IV focuses on building and strengthening the foundational capabilities required to perform successfully.

End Part III End Part III

Readiness determines the pathway, not the other way around.

Part IV:

Building Foundational Capabilities What must be in place before we move forward?

Challenge: Build Intentionally

PART IV Objectives Upon completion of Part IV, you will be able to 1. Identify the foundational capabilities needed to support Value-Based Care performance 2. Prioritize capability gaps that should be addressed before moving forward 3. Determine which capabilities to build or strengthen internally and which to access through strategic partners or shared services 4. Align capability development with your selected Value-Based Care pathway 5. Develop a focused capability-building plan

Building Foundational Capabilities Introduction Part II identiﬁed your organization’s strengths and capability gaps. Part III helped you evaluate the ValueBased Care pathway that best aligns with your current readiness and goals. Now it is time to strengthen the capabilities needed to move forward. The same six domains used to assess readiness provide the framework for capability development: • • • • •

Leadership & Governance Clinical Operational Data & Technology Financial

Quality & Compliance Not every capability needs to be built internally. Some may already exist. Others can be strengthened through strategic partnerships or shared services. Focus ﬁrst on the capabilities most critical to your selected pathway.

Note: Activity vs Capability An activity is something you do. A capability is something your organization can do reliably and consistently. Successful Value-Based Care performance demands reliable, repeatable capabilities that move outcomes. It does not reward effort without results.

Leadership & Governance Capability Driving Principle: Leadership establishes the vision. Governance provides the structure. Together, they create organizational alignment and accountability for Value-Based Care success. Key Question

Does our organization have the leadership commitment, governance structure, and accountability needed to sustain Value-Based Care transformation? Leadership and governance provide the direction and structure needed to move forward. Before advancing, organizations should have the following foundational capabilities in place or actively strengthen them as part of their Value-Based Care pathway.

Foundational Leadership & Governance Capabilities 1. Vision & Direction

Leadership establishes a clear Value-Based Care vision that guides organizational priorities and investment.

2. Governance & Decision-Making

3. Organizational Alignment

Leadership aligns priorities and resources around the organization’s Value-Based Care goals.

4. Accountability & Ownership

Delegates clear ownership, decision authority, establishes performance expectations, and holds designated owners accountable for results.

5. Culture & Change Leadership

Leaders actively guide change and reinforce shared ownership throughout implementation.

6. Continuous Improvement

Uses performance results and lessons learned to strengthen the organization over time.

✱IF YOU REMEMBER NOTHING ELSE… •

Leadership sets a clear direction for Value-Based Care.

•

It delegates ownership and decision authority explicitly and

•

Uses performance results to drive organizational improvement.

BEST PRACTICE Establish a multidisciplinary Value-Based Care leadership structure that reviews performance, aligns priorities, removes barriers, and holds designated owners accountable for results

WORD TO THE WISE Leadership misalignment will undermine even strong capabilities.

Related Tools Appendix 1: Organizational Capability Inventory & Readiness Assessment

Clinical Capability Driving Principle: The patient journey is the operating system of Value-Based Care.

Key Question Can our organization consistently deliver coordinated, proactive, evidence-based care across the patient’s entire journey? Value-Based Care requires clinical capabilities that extend beyond individual encounters. Before moving forward, organizations need reliable systems to anticipate patient needs and manage care across the patient journey.

Foundational Clinical Capabilities 1.

Patient Journey Design Mapping & Longitudinal Patient Management

Map how patients move through care to identify communication preferences, gaps, failed handoffs, and points where patients may fall through the cracks. Get speciﬁc. Use those ﬁndings to design proactive care that follows patients across time, settings, and between encounters. 2.

Proactive Prevention & Early Intervention

Risk Stratiﬁcation

Build clinical workﬂows that identify risk and support timely intervention before avoidable disease progression or utilization occurs. Clearly deﬁne who does what, when, and where. Include handoff and escalation points. Stratify patients by clinical risk and use that information to prioritize interventions and direct resources where they can have the greatest impact.

Evidence-Based Care Delivery

Care Coordination and Care Transitions

Patient & Caregiver Engagement

Standardize evidence-based clinical workflows and protocols to support consistent care while preserving appropriate clinical judgment. Define communication, referral, handoff, and follow-up processes that maintain continuity across providers and care settings. Assign ownership so the loop is closed. Build workflows for these! Engage patients and caregivers as active partners in care. Build shared decision-making and ongoing communication into the care model.

✱IF YOU REMEMBER NOTHING ELSE… •

Design care around the patient journey.

•

Manage risk proactively and continually.

•

Build continuity into what happens between visits.

BEST PRACTICE Map your patient journey before redesigning your clinical model. Identify where patients, information, and accountability are most likely to fall through the cracks. Then strengthen those processes before expanding services or assuming greater ﬁnancial accountability.

WORD TO THE WISE If you can’t close the cracks, don’t agree to risk.

Related Tools Appendix 4: Patient Journey Mapping Template Appendix 5: Risk Stratiﬁcation Worksheet Appendix 6: Closed-Loop Referral Process Checklist Appendix 7: Care Transition Mapping Tool Appendix 8: Workﬂow Mapping Template

Operational Capability Driving Principle: Reliable, well-designed workﬂows turn clinical intent into consistent performance.

Key Question Can our operations reliably support the people, processes, and workflows required to deliver measurable results? Operational capability turns the care model into daily practice. Before moving forward, organizations need defined workflows, clear ownership, and reliable processes that support consistent execution.

Foundational Operational Capabilities 1.

Workﬂow Design & Process Standardization

Communication & Information Flow

Deﬁned Roles, Responsibilities and Accountability

Interdisciplinary Team Operations

Strategic Resource Integration

Design and standardize workflows that support reliable execution of the care model. Establish reliable communication pathways so information reaches the right people when action is needed. Define who owns each process, who performs the work, where team handoffs occur and to whom, and where accountability sits. Organize interdisciplinary teams around defined roles and coordinated workflows that support the patient journey. Integrate internal resources, strategic partners, and shared services into workflows so responsibilities and handoffs are clear.

✱IF YOU REMEMBER NOTHING ELSE… • • •

Design cross-functional workflows before expecting consistent execution. Define ownership and accountability at every handoff. Integrate partners and shared services into existing workflows.

BEST PRACTICE Design and standardize critical workflows before adding resources or technology. Define ownership and handoffs first, then build support around the work.

WORD TO THE WISE Temporary workarounds have a way of becoming permanent. Replace them as soon as possible with standardized, sustainable processes.

Related Tools Appendix 8: Workﬂow Mapping Tool Appendix 9: Roles & Responsibilities Accountability Template Appendix 10: Strategic Partnership & Shared Services Evaluation Tool

Data & Technology Capability Driving Principle: Data creates visibility. Technology makes it actionable. Key Question Can our organization reliably capture, access, and use the information needed to support care delivery and Value-Based Care performance? Data and technology capabilities provide the information infrastructure needed to manage care and measure performance. Before moving forward, organizations need reliable access to accurate, timely, and actionable information.

Foundational Data and Technology Capabilities 1. Data Collection & Integration

Collect and integrate clinical, operational, ﬁnancial, and quality data are accurately collected and integrated to support organizational decision-making.

2. Data Quality & Governance

Establish standardized deﬁnition, processes, and accountability to ensure data are complete, accurate, timely and reliable.

3. Performance Measurement & Reporting

Measure and report meaningful performance data so designated owners can monitor results and identify areas requiring attention.

4. Analytics, Decision Support & Population Health

Translate data into actionable information that supports population health management, clinical decision-making, operational improvement, and strategic planning.

5. Technology Enabled Workﬂows

Integrate technology into workﬂows to support communication, automation, access to information, and timely decision-making without adding unnecessary care complexity or burden. © 2026 Synergy 3C – The Clinical Consulting Cooperative, LLC. All Rights Reserved.

6. Interoperability & Information Exchange

Enable secure, reliable information exchange across systems, providers, and care settings to support and facilitate coordinated care.

✱IF YOU REMEMBER NOTHING ELSE… • • •

•

Design the clinical workflow first. Configure technology to support it. Keep critical information within two clicks for the user. Protect data quality from collection through reporting. Put actionable data at the team’s fingertips.

BEST PRACTICE Design the workflow first, then select and configure technology to support it. Test usability with the people who will actually use it before implementation (User Acceptance Testing).

WORD TO THE WISE Don’t Mistake More Data for Better Decisions – More data creates value only when it helps teams make better decisions and take appropriate action. Technology follows the workflow - Never allow technology configuration to dictate clinical workflow.

Related Tools Appendix 11: Technology Inventory Worksheet Reference: Appendix 10: Strategic Partnership & Shared Service Evaluation Tool / Technology Section Appendix 12: Interoperability Planning Checklist Appendix 13: Data Governance Checklist

Financial Capability Driving Principle: You cannot manage Value-Based Care performance if you do not understand the economics behind it. Key Question Can our organization understand, model, monitor, and manage the ﬁnancial implications of our selected Value-Based Care payment arrangement?

Financial capability connects care delivery to economic performance. Before moving forward, organizations need to understand how payment is earned, what drives ﬁnancial results, and whether the arrangement is sustainable.

Foundational Financial Capabilities 1. Contract Evaluation & Readiness Evaluate proposed payment arrangements to determine ﬁnancial requirements, performance expectations, potential exposure, and whether the organization has the ﬁnancial capacity to participate.

2. Payment Model & Contract Economics

Understand how payment is structured, how revenue is earned, what performance requirements apply, and where ﬁnancial exposure exists.

3. Financial Modeling & Forecasting

Model expected revenue, costs, resource requirements, and potential ﬁnancial outcomes before entering an arrangement.

4. Investment & ROI Analysis

Evaluate the resources required to implement the selected pathway and determine whether the expected clinical, operational, and ﬁnancial value justiﬁes the investment.

5. Cost & Utilization Management

In collaboration with clinical leadership, identify the clinical and utilization patterns that drive cost to determine where appropriate intervention can improve outcomes and ﬁnancial performance.

6. Performance Tracking & Variance Management Monitor actual ﬁnancial performance against expectations and investigate meaningful variance before it becomes a larger problem.

7. Reconciliation & Payment Validation

Validate payer reports, performance calculations, attribution, payments, and reconciliation results to conﬁrm that ﬁnancial outcomes are accurate.

8. Financial Sustainability & Resource Planning

Determine whether the organization has the ﬁnancial capacity and resources needed to implement and sustain the selected pathway.

✱IF YOU REMEMBER NOTHING ELSE… •

Know exactly how payment is earned and calculated.

•

Model the ﬁnancial impact before signing the contract.

•

Connect clinical and utilization performance to ﬁnancial results.

•

Validate your own numbers. Never assume the payer got them right.

BEST PRACTICE Model the arrangement before you enter it. Establish expected clinical and ﬁnancial performance, required investment, and anticipated ROI so you have a baseline to measure actual results against.

A BIG WORD TO THE WISE – REDUCE YOUR VARIANCE Clinical variance creates outcome variance. Outcome variance creates financial variance. Strong clinical and operational workflows reduce unnecessary variance, improve outcome predictability, and strengthen financial performance. Managing variance is fundamental to sustainable Value-Based Care.

Related Tools Appendix 14: Value-Based Care Contract Evaluation Guide Appendix 15: Financial Modeling & ROI Worksheet

Quality & Compliance Capability Driving Principle: What gets measured must lead to action. Key Question Can our organization reliably measure, monitor, and improve clinical quality while meeting regulatory, contractual, and compliance requirements? Quality and compliance capabilities provide the oversight needed to protect performance and organizational integrity. Before moving forward, organizations need deﬁned measures, reliable monitoring processes, and clear mechanisms to identify gaps and act on ﬁndings.

Foundational Quality & Compliance Capabilities 1. Clinical Performance & Quality Improvement Establish a structured approach to measure and monitor clinical performance, identify gaps, implement improvement strategies, and verify results.

2. Quality Monitoring & Reporting Deﬁne the quality and outcome measures that apply to the selected Value-Based Care pathway. Establish reliable processes to capture, validate, monitor, and report performance.

3. Quality Assurance & Oversight Establish formal Quality Assurance oversight with clear authority to review performance, identify concerns, assign corrective action, and monitor follow-through.

4. Regulatory & Contractual Compliance Identify applicable regulatory, payer, and contractual requirements. Assign ownership and establish processes to monitor compliance and address deﬁciencies.

5. Documentation & Coding Integrity Maintain accurate, complete, and compliant documentation and coding that reﬂect care delivered and support quality, risk adjustment, and payment requirements.

6. Patient Safety & Risk Management Establish processes to identify, report, evaluate, and address patient safety events and clinical risks that may affect patient outcomes or organizational performance.

✱IF YOU REMEMBER NOTHING ELSE… •

Deﬁne what you will measure before performance begins.

•

Monitor performance routinely and act when gaps emerge.

•

Assign ownership for corrective action and verify resolution.

•

Protect documentation integrity and patient safety throughout the process.

BEST PRACTICE Establish a formal Quality Assurance structure that routinely reviews clinical performance and compliance, identiﬁes gaps, assigns corrective action, and veriﬁes improvement

WORD TO THE WISE Measurement without action is surveillance, not improvement.

Related Tools Appendix 16: Core Value-Based Care Metrics Dashboard Appendix 17: Performance Improvement Drivers - Fish Bone Appendix 18: Performance Improvement Action Plan Appendix 19: Quality Assurance / Performance Improvement Committee Template Appendix 20: Compliance Requirements Checklist

Summary Capabilities Build Readiness Value-Based Care performance depends on capabilities that work together across the organization. Each domain has a primary area of ownership, but none operates independently. Together, these six domains create the foundation needed to move forward with greater conﬁdence and control.

WORD TO THE WISE Set realistic timelines. Building a capability takes more than implementation. Allow time to test, validate, and stabilize it before depending on it for performance. When timelines slip, reassess the plan rather than allowing temporary workarounds to become permanent practice. The question to ask: Are our timelines realistic, including the time required to build, test, validate, and stabilize critical capabilities?

Before Moving Forward Conﬁrm that your organization can •

Set direction, delegate ownership, and maintain accountability.

•

Deliver proactive, coordinated care across the patient journey.

•

Execute reliable workﬂows with clear roles and handoffs.

•

Capture, exchange, and use actionable data.

•

Model and manage the ﬁnancial implications of the pathway.

•

Measure clinical performance, maintain compliance, and act on identiﬁed gaps.

What must be in place before we move forward? Enough capability to execute reliably, measure performance, and know when you are ready for greater accountability.

End Part IV

Never sign a contract you cannot model and measure.

Part V:

Pilot, Learn, Improve, and Progress How do we pilot, learn, improve, and build a sustainable Value-Based Care roadmap over time?

Challenge: Implement Conﬁdently

PART V Objectives Upon completion of Part IV, you will be able to 1. Use readiness findings to identify priorities for implementation 2. Select an initial pilot aligned with organizational capabilities, priorities, and resources 3. Prioritize the capabilities most critical to pilot success 4. Initiate a Value-Based Care roadmap that supports deliberate growth over time 5. Apply pilot findings to strengthen workflows, capabilities, and performance 6. Determine when to strengthen, expand, or progress along your Value-Based Care roadmap

Don’t Wait. Start Building! Driving Principle: Sustainable Value-Based Care is built by starting deliberately, measuring what matters, learning from experience, and building on success over time. Start with a manageable pilot. Measure performance, learn from the experience, strengthen what needs improvement, and use those ﬁndings to determine your next step.

Key Question Every organization starts from a different place. Build a roadmap that reﬂects your priorities, capabilities, resources, and long-term goals.

Two Transformation Paths. One Strategic Choice Organizations commonly enter Value-Based Care through one of two paths. Both can lead to success, but the experience getting there can look very different.

Unaligned Path A Value-Based Care opportunity or contract comes ﬁrst, before organizational goals, readiness, and required capabilities are fully aligned. The organization must build or strengthen capabilities while performance is already underway. Success is possible, but the path often brings greater disruption, rework, performance variability, and risk.

Strategic Path Organizational goals and readiness guide the path forward. The organization identifies what it wants to accomplish, assesses and strengthens the capabilities required for success, and selects an OutcomeAligned Payment opportunity that fits its goals and readiness. This creates a more deliberate path to implementation and reduces avoidable performance risk. Both paths eventually reach a Pivot, where performance results and lessons learned inform what comes next. The organization may refine its strategy, strengthen capabilities, expand what is working, or adjust course before progressing.

Building Your Roadmap Every organization’s Value-Based Care roadmap will reﬂect its goals, capabilities, resources, and starting point. Build yours deliberately, beginning with what your organization is prepared to execute successfully today and creating a path for growth over time.

Step 1. Start with Your Destination Why This Matters Define what success looks like for your organization before deciding how to pursue Value-Based Care. Your priorities should guide the populations you serve, the capabilities you build, the partnerships you establish, and the Outcome-Aligned Payment opportunities you pursue. Whether your priority is improving access, strengthening financial sustainability, reducing avoidable utilization, or improving outcomes for a specific population, Value-Based Care becomes the strategy for getting there.

BEST PRACTICE Deﬁne organizational success before evaluating Outcome-Aligned Payment opportunities. Payment should support organizational strategy, not determine it.

Questions to Answer Before Moving Forward Before evaluating an Outcome-Aligned Payment model, leadership should be able to answer the following questions: •

What are we trying to accomplish?

•

Which patients or populations will beneﬁt most from our initial efforts?

•

What organizational challenges are we trying to solve?

•

What outcomes will deﬁne success?

•

How will we measure success?

•

What level of performance risk are we prepared to assume?

✱IF YOU REMEMBER NOTHING ELSE…

The most successful Value-Based Care organizations do not chase payment models. They build the capabilities required to succeed under them.

WORD TO THE WISE A payment opportunity can be attractive and still be wrong for your organization. Start with where you are going, then evaluate whether the opportunity helps you get there.

Related Tools Appendix 21: Organizational Destination Planning Worksheet Appendix 22: Leadership Alignment Discussion Guide

Step 2. Know Where You Stand Why This Matters Your destination establishes where you want to go. Your previous readiness and capability work establishes where you begin. Use those ﬁndings to identify what you can reliably execute today and what could affect successful implementation. You do not need every capability fully developed before moving forward. You do need a clear view of what is working, what needs strengthening, and what matters most for the pathway you intend to pursue.

BEST PRACTICE Assess your current state objectively. Build on demonstrated strengths and address the gaps that could compromise successful implementation. When appropriate, an outside perspective can help identify blind spots that may otherwise go unnoticed.

Questions to Consider as You Move Forward •

What can we reliably execute today?

•

Where could existing gaps compromise implementation or performance?

•

What needs to be strengthened before we launch?

•

What can be supported through strategic partners or shared services?

•

Which existing strengths give us the best foundation to build upon?

Through the Looking Glass: From Readiness to Implementation You have already assessed your readiness and identiﬁed the foundational capabilities needed for ValueBased Care. Now look at those same six domains through an implementation lens. The question is no longer how ready each domain is. The question now is what each domain must contribute to the success of your initial implementation.

Domain

Implementation Question

Leadership & Governance

Who owns the initiative, who has the decision authority, and are the necessary resources committed?

Clinical

What must be reliability delivered across the patient journey for this population to achieve the intended outcomes?

Operational

What workﬂows, roles, handoffs, and accountabilities must function reliably from day one? What are our workarounds?

Data & Technology

What information must be available, to whom, and when to support execution and measure performance?

Financial

What will implementation require ﬁnancially, how will performance affect reimbursement, and how will we know whether the investment is producing value?

Quality & Compliance

What must we measure, monitor, and oversee to protect quality, patient safety, compliance, and performance?

WORD TO THE WISE Be rigorous about what is truly operational. A capability that exists on paper but is not executed consistently is not ready.

Step 3: Prioritize What Matters Most Why This Matters Identifying capability gaps does not tell you where to begin. Few organizations have the time, resources, or workforce to strengthen everything at once. Prioritize the capabilities that will have the greatest impact on your initial implementation and organizational goals. Use the 80/20 Rule to focus your effort. A relatively small number of capabilities will drive the majority of early success. Build those ﬁrst.

Synergy Principle: The 80/20 Rule Organizations do not need every Value-Based Care capability fully developed before launching a Minimum Viable Pilot (MVP). However, they should ensure that approximately 80% of the critical capabilities required for success are functioning reliably before assuming greater accountability. Critical capabilities may be •

Fully developed internally

•

Supported through a temporary workaround while a permanent solution is implemented

•

Provided through a strategic partner

•

Delivered through a shared service

What matters is that the capability functions reliably without creating unacceptable burden, inefficiency, or risk. Temporary workarounds should be actively evaluated and replaced when they create unnecessary complexity or inefficiency. Do not allow a workaround that “works” to become the permanent workﬂow simply because it works. Strategic partnerships and shared services may remain appropriate long-term solutions when they provide greater expertise, efficiency, scalability, or cost-effectiveness than building internally.

BEST PRACTICE Prioritize the capabilities that create the greatest value for your organization — not simply the ones that are easiest to improve.

Priority Decisions for Moving Forward For each capability identiﬁed in Step 2, determine the following: •

Is it critical to the success of our initial implementation?

•

What happens if it does not function reliably?

•

Which capability gaps present the greatest risk to the success of our MVP?

•

Must it be strengthened before launch, or can it improve during implementation?

•

Should we build it internally, use a strategic partner, or access a shared service?

•

Do we have the resources and ownership required to execute it?

✱IF YOU REMEMBER NOTHING ELSE…

Not every gap deserves immediate attention. Prioritize the capabilities that will have the greatest impact on the success of your initial implementation.

WORD TO THE WISE The 80/20 Rule is your friend, and it is about prioritization. Resist the temptation to improve everything at once. Focus ﬁrst on the capabilities that matter most. Those are the ones that must work reliably before you depend on them for performance.

Related Tools Appendix 23: Capability Prioritization Matrix Reference Appendix 10: Strategic Partnership and Shared Services Decision Guide Appendix 24: Strategic Partnership Planning Worksheet

Step 4: Design Your Minimum Viable Pilot (MVP) Why This Matters Your initial pilot should be large enough to test whether your model works and small enough to identify and correct problems without creating unnecessary organizational or financial risk. Start with a defined population, focused objectives, and a manageable scope. Use the pilot to test how your clinical model, workflows, technology, measurement, and financial assumptions perform together under real-world conditions.

BEST PRACTICE Start with one payer, one deﬁned patient population, one focused set of objectives, and one welldesigned Minimum Viable Pilot (MVP). Learn deliberately. Improve continuously. Then build boldly.

Designing Your Minimum Viable Pilot (MVP) Every successful MVP design answers five fundamental questions: 1. What are We Trying to Accomplish? Define the specific problem the pilot is intended to address and the outcomes you expect to influence, e.g. objectives success measures, etc.

2. Who Are We Serving? Deﬁne the patient population narrowly enough to understand who is included and not included, what they need, and how success will be measured. Map the patient journey for the selected population before launch. Identify where patients may experience gaps, delays, or failed handoffs and address those vulnerabilities in the pilot design.

3. How Will We Deliver It? Deﬁne the care model, workﬂows, roles, handoffs, technology, partners, necessary policies, procedures, job aids, and resources required to execute the pilot reliably. Assign clear ownership for the work before implementation begins.

4. How Will We Know It Worked? Define success before the pilot begins. Select a focused set of clinical, operational, financial, quality, and patient-centered measures that reflect the pilot's objectives and can be measured reliably. Establish the baseline expectation before implementation whenever possible. 5. What Did We Learn? Build learning into the pilot from the beginning. Capture what worked well, what did not work as intended, where unexpected barriers emerged, and what should change before the next cycle. A facilitated SWOT analysis can provide a simple, structured way to examine the pilot from multiple perspectives and identify strengths to preserve, weaknesses to address, opportunities to pursue, and threats that could affect future success. Include the people closest to the work. Frontline team members, operational leaders, clinical stakeholders, and other key participants often identify issues and opportunities that performance data alone cannot reveal.

✱IF YOU REMEMBER NOTHING ELSE…

Map the patient journey before designing your MVP. The patient journey reveals where patients experience delays, gaps, failed handoffs, and variation. Use those insights to design the clinical and operational workﬂows your MVP must test. Your ﬁrst pilot should be focused enough to expose weaknesses, generate meaningful evidence, and allow you to learn without creating unnecessary organizational risk.

BEST PRACTICE Start with one payer, one deﬁned patient population, one focused set of objectives, and one welldesigned pilot. Create enough scope to test the model meaningfully without introducing unnecessary complexity.

WORD TO THE WISE Early success builds conﬁdence and organizational momentum. Narrow the initial scope enough to identify what works, correct what does not, and strengthen the model before expanding it. A successful pilot also produces meaningful learning. Every lesson strengthens organizational capability, reduces variance, and better prepares your organization for what comes next.

Related Tools Appendix 25: MVP Scope Planning Template Appendix 26: Vision & Direction Communication Planner Appendix 27: MVP Planning Template Reference Appendix 4: Patient Journey Mapping Tool Reference Appendix 9: Roles, Responsibilities & Accountability Template Reference Appendix 16: Core Value-Based Care Metrics Dashboard

Step 5: Measure, Learn, & Strengthen Why This Matters A pilot creates value when performance results and lessons learned lead to action. Measure results against the objectives and baseline established before launch, identify what worked and what needs improvement, and strengthen the model based on what the evidence shows.

BEST PRACTICE Establish a regular cadence for performance review. Use it to identify opportunities for improvement, develop an improvement plan, and hold the organization accountable for implementation. Small, consistent improvements produce lasting organizational change.

Evaluate the Pilot 1. What Worked Well? Identify the workﬂows, capabilities, partnerships, and approaches that performed as intended and contributed to successful results. Ask: • Did the pilot achieve its deﬁned objectives and expected outcomes? • What performed as expected? • What contributed most to successful performance? • What should be preserved or standardized?

2. What Needs Improvement?

Identify where performance fell short, workﬂows broke down, unnecessary variation occurred, or the experience created burden for patients or the care team. Ask: • • • • •

Where did performance fall short? Where did workﬂows, handoffs, or processes break down? What created unnecessary burden, delay, or variation? Which issues require corrective action or deeper root cause analysis? What needs to change before the next cycle?

3. Strengthen the Model

Translate findings into specific improvements before deciding whether to expand or progress. Assign ownership, establish timelines, and determine how improvement will be verified. Ask: • • • •

What needs to change? Who owns each improvement? What must be addressed before moving forward? How will we know the change produced the intended improvement?

✱IF YOU REMEMBER NOTHING ELSE…

Every pilot should leave your organization stronger than when it began.

BEST PRACTICE Early wins build conﬁdence. Lessons learned build capability.

Related Tools: Appendix 29: MVP Evaluation & Lessons Learned Template Reference Appendix 18: Performance Improvement Action Plan Appendix 30: Pilot SWOT Analysis Template Appendix 31: Root Cause Analysis Template

Step 6: Determine What Comes Next Why This Matters Completing a pilot does not automatically mean an organization is ready to expand or assume greater accountability. Use demonstrated performance, organizational capability, and lessons learned to determine the appropriate next step. This is the Pivot: the point where evidence informs what comes next.

✱IF YOU REMEMBER NOTHING ELSE…

Progress no sooner than when evidence supports it.

Determine Your Next Steps ❶ Strengthen Address identiﬁed gaps, reﬁne the model, and continue or repeat the pilot before expanding. ❷ Expand Extend a demonstrated model to a larger population, additional payer, or broader scope when performance supports doing so.

❸ Progress Move to the next appropriate opportunity on your Value-Based Care roadmap when performance and organizational capabilities support greater accountability.

Questions to Consider • • • • •

•

Did the pilot achieve the outcomes required to support advancement? Are the critical workﬂows and capabilities functioning reliably? Have signiﬁcant gaps, unintended consequences, or performance concerns been addressed? Can the organization sustain current performance at a larger scale? What level of additional accountability is the organization prepared to assume? What do the evidence and experience tell us we are ready to do next?

Document the decision and use it to deﬁne the next stage of your Value-Based Care roadmap.

✱IF YOU REMEMBER NOTHING ELSE…

Progress when the evidence supports it, not because the calendar says it is time.

Related Tools Appendix 32: Value-Based Care Roadmap Planning Tool Appendix 33: “Are We Ready to Advance?” Decision Tool

End Part V

!! Start focused. Learn deliberately. Strengthen before you scale!

Closing: From Playbook to Practice Put this playbook to work! Value-Based Care becomes real when the work moves from planning to practice. Use this playbook to align leadership, guide strategic decisions, assess readiness, prioritize capabilities, and build a common language across your organization. Bring it into leadership meetings and strategic planning. Use the tools. Write in the margins. Challenge assumptions. Adapt what needs adapting. Return to it as your organization grows. Most importantly, make it a team sport. There is no “I” in Value-Based Care! Put it in the hands of the people responsible for designing, delivering, measuring, and improving care. Transformation requires people across the organization to know where you are going, understand their role, and work toward the same goals.

Every meaningful transformation begins with a single decision to act differently.

Build the care model you’d want for yourself and your family.

Selected References This playbook reﬂects current evidence, publicly available guidance, industry best practices, and the author's professional experience designing and implementing Value-Based Care models across diverse healthcare settings. The following references and resources provide additional information for organizations seeking to strengthen their Value-Based Care knowledge and implementation efforts.

Federal: • • • • • • •

Centers for Medicare & Medicaid Services (CMS) CMS Innovation Center (CMMI) Medicare Learning Network (MLN) Agency for Healthcare Research and Quality (AHRQ) Office of the National Coordinator for Health Information Technology (ONC) Health Resources and Services Administration (HRSA) Centers for Disease Control and Prevention (CDC), as appropriate

Quality, Measurement, and Population Health: • • • • •

National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS®) Merit-based Incentive Payment System (MIPS) Quality Payment Program (QPP) International Consortium for Health Outcomes Measurement (ICHOM)

Value-Based Care and Payment: • •

Health Care Payment Learning & Action Network (LAN) National Association of ACOs (NAACOS)

Rural Health: • •

National Rural Health Association (NRHA) Rural Health Information Hub (RHIhub)

Improvement Science and Leadership: • •

Institute for Healthcare Improvement (IHI) The Advisory Board

For Further Reading Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The Triple Aim: Care, health, and cost. Health Affairs, 27(3), 759–769. https://doi.org/10.1377/hlthaff.27.3.759 Bodenheimer, T., & Sinsky, C. (2014). From Triple to Quadruple Aim: Care of the patient requires care of the provider. The Annals of Family Medicine, 12(6), 573–576. https://doi.org/10.1370/afm.1713 Kotter, J. P. (1996). Leading change. Harvard Business School Press. Porter, M. E. (2010). What is value in health care? The New England Journal of Medicine, 363(26), 2477– 2481. https://doi.org/10.1056/NEJMp1011024

Appendices Resources and Support Tools

Appendix 1: Organizational Capability Inventory & Readiness Assessment Organizational Capability Inventory Purpose

Identify existing capabilities, capability gaps, and how capabilities are currently delivered.

Instructions Before evaluating readiness, identify which capabilities currently exist within your organization and how they are being delivered. Capabilities may be provided internally, through strategic partners, through shared service arrangements, or may not currently be available.

Important Consideration The goal is not to build every capability internally. The goal is to ensure the capability exists and performs effectively.

Rural Health Reality Many successful rural healthcare organizations intentionally leverage strategic partners and shared services to access capabilities that would be difficult, costly, or unnecessary to build internally. Internal Team

Strategic Partner

Shared Service

Not Available Now

Critical Gap?

Care Management Services

☐

Patient Navigation

☐

Risk Stratiﬁcation

☐

Data & Analytics

☐

Quality Reporting

☐

Referral Management & Loop Closure

☐

Transitional Care Management

☐

Behavioral Health Support

☐

Pharmacy Support

☐

Community Resource Navigation

☐

Patient Outreach & Engagement

☐

Contracting & VBC Strategy Support

☐

Financial & Performance Analytics

☐

Capability

Notes:

Identiﬁed Critical Gaps List any capabilities identiﬁed as critical gaps and describe how the organization intends to address them. Critical Capability Gap

Build Internally

Strategic Partner

Shared Service

☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

Target Date

Purpose

Assess organizational readiness across the six readiness domains: Clinical, Operational, Data & Technology, Financial, Leadership & Governance, and Quality & Compliance.

Notes

Readiness Assessment: Leadership and Governance Readiness Current

Future Plan

Critical Gap

Does leadership understand VBC and have a willingness to change culture?

☐

Do you have a performance management program (e.g. PDSA)?

☐

Do the executives and/or board members have a vision to improve holistic wellbeing vs. continuing FFS reactional care?

☐

Is there a willingness to align quality, cost control and wellness into care plans and patient goals?

☐

Do you have expertise in navigating payer contracts, risk-sharing arrangements and regulatory compliance?

☐

Is there clinical and operational accountability and clearly deﬁned roles?

☐

Are incentives aligned with VBC operational and clinical goals?

☐

Is there a strategic plan to execute on VBC initiatives?

☐

Are processes, systems, and behaviors ready to support the change?

☐

Do leaders know how to manage change and have the required capabilities to inspire trust?

☐

Is there time, staffing, budget, and bandwidth to absorb the change?

☐

Is your communication consistent across leadership, department, or teams?

☐

Leadership and Governance Readiness

Notes

Readiness Assessment: Clinical Readiness Current

Future Plan

Critical Gap

Do you have a process that allows you to anticipate patient needs and proactively manage risk?

☐

Are you able to identify changes in condition and intervene early?

☐

Do you monitor patient outcomes and use performance data to improve care?

☐

Do you have little or no variation in care delivery across providers?

☐

Do you practice proactive prevention through early identiﬁcation, timely assessment and intervention before manageable problems become ED visits

☐

Is patient experience measured?

☐

Do you have chronic disease management program(s)?

☐

Are all patients screened for depression?

☐

Are patients screened for anxiety?

☐

Do you emphasize cancer screenings for breast, colorectal, cervical, lung (smokers), and prostate?

☐

Do you track immunizations for all patients?

☐

Do you complete Advanced Care Planning for MCR patients?

☐

Are all patients assessed for social determinants of Health?

☐

Are patients screened for fall risk?

☐

Do you coordinate care across settings and providers?

☐

Do you maintain meaningful engagement with patients between visits?

☐

Clinical Readiness

Notes

Readiness Assessment: Operational Readiness Current

Future Plan

Critical Gap

Do you have standardized clinical and operational workﬂows?

☐

Do you have clearly deﬁned roles, responsibilities & accountability?

☐

Do you coordinate work across teams with reliable handoffs?

☐

Have you mapped how patients move through the organization & identiﬁed where they may fall through the cracks?

☐

Do you have same day sick visits?

☐

Do you perform telehealth visits?

☐

Do have a process to follow up on missed visits?

☐

Do you have an online check-in process?

☐

Are patients proactively informed of delays while waiting?

☐

Do you have resources to meet SDOH needs?

☐

Do you coordinate services across providers, settings, and community resources?

☐

Do you assess medication adherence and affordability?

☐

Do you perform fall risk assessments as needed?

☐

Do you have after hours call?

☐

Do you have access to ADT feeds?

☐

Are transitional care visits scheduled within 14 days of discharge?

☐

Do you maintain closed-loop referral and care transition processes?

☐

Do providers understand ICD-10 coding speciﬁcity and HCC?

☐

Is there a process for recapturing HCCs?

☐

Is there a billing audit program?

☐

Are z-codes used for SDOH issues?

☐

Do you perform AWVs?

☐

Is there a documentation audit program?

☐

Are care plans created, executed, and updated?

☐

Do you have relationships with high quality post-acute providers (e.g. home health, outpatient therapy, hospice)?

☐

Operational Readiness

Notes

Readiness Assessment: Data and Technology Readiness Current

Future Plan

Critical Gap

Do you use certiﬁed EHR technology (CEHRT)?

☐

Do you stratify patients based on risk and need?

☐

Do you have access to timely and actionable clinical, quality, utilization and ﬁnancial data?

☐

Do you use data to support clinical, operational, and ﬁnancial decision-making

☐

Do you have a patient portal?

☐

Do you have a mobile application?

☐

Do you have a cybersecurity infrastructure?

☐

Do you use AI for decision support or transcription?

☐

Can you monitor quality, outcomes, utilization, and cost performance

☐

Can you track progress toward organization goals and VBC objectives?

☐

Do you share information across care teams to support coordinated patient management?

☐

Do you receive timely information from providers, facilities, or other care settings when needed to support care coordination and transitions?

☐

Data and Technology Readiness

Notes

Readiness Assessment: Financial Readiness Current

Future Plan

Critical Gap

Do you evaluate outcome-aligned payment models for their ﬁnancial structure, performance requirements, and level of ﬁnancial accountability?

☐

Do you recognize how clinical and operational performance inﬂuence ﬁnancial performance?

☐

Will ﬁnance be included in the decision on which VBC opportunity to consider?

☐

Will you monitor ﬁnancial performance associated with VBC activities and contracts?

☐

Will you align payment opportunities with organizational capabilities, resources, and goals?

☐

Do you track ﬁnancial targets and compare performance over time?

☐

Can you assess current state of cash ﬂow and cash reserves?

☐

Will you evaluate ﬁnancial exposure before entering into contractual arrangements?

☐

Do you have funding for care coordination, preventative services and/or population health initiatives?

☐

Are you willing to invest in staff training?

☐

Do you have funding for technology and integration costs?

☐

Are you able to assess your shared savings potential?

☐

Financial Readiness

Notes

Readiness Assessment: Quality & Compliance Readiness Current

Future Plan

Critical Gap

Do you consistently identify applicable quality, regulatory, contractual, and reporting requirements for your contracts?

☐

Can you translate the requirements into workﬂows with clear ownership and accountability

☐

Do you capture and validate data needed to measure and report performance?

☐

Do you monitor quality, outcomes, and compliance performance and address identiﬁed gaps?

☐

Does your documentation support care delivery, reporting and reimbursement?

☐

Do you have a standardized compliance program?

☐

Do you have a process for educating providers about documentation deﬁciencies?

☐

Are providers held accountable for patient satisfaction and quality outcomes?

☐

Do you have policies and procedures to standardize VBC processes and expectations?

☐

Quality & Compliance Readiness

Notes

Identiﬁed Critical Gaps List any capabilities identiﬁed as critical gaps and describe how the organization intends to address them. Critical Capability Gap

Build Internally

Strategic Partner

Shared Service

☐

Target Date

✱IF YOU REMEMBER NOTHING ELSE…

Readiness is more than having the right boxes checked—it is having the capacity, commitment, and capability to execute.

An organization may have strong clinical programs, sophisticated technology, ﬁnancial resources, and supportive leadership, yet still struggle with Value-Based Care if these capabilities do not work together. Use this assessment to identify not only what is in place today, but also what must change to support the organization’s future state. Be honest about the critical gaps. A gap is not a failure—it is a starting point for action. The most important question is not “Are we ready?” but “What must we build, change, or strengthen to become ready?” Readiness should ultimately connect people, processes, technology, ﬁnances, and leadership around a common purpose: delivering better outcomes and experiences for patients while creating sustainable value.

WORD TO THE WISE You cannot execute a Value-Based Care strategy that your organization is not equipped to support. Know your gaps, prioritize them, and build readiness before taking on risk.

This appendix is referenced in Part II: Assessing Readiness Notes:

Appendix 2: Collaborative Structure Selection Guide Purpose This Guide helps organizations evaluate how they should organize the delivery of care and supporting capabilities as they pursue Value-Based Care. The guide distinguishes between delivery structures, shared services, and payment models—three related but different decisions. It helps organizations consider their VBC strategy, current capabilities, need for shared infrastructure, desired level of independence, and readiness for greater collaboration. The goal is not to identify a single “best” structure. Rather, it is to identify the structure—or combination of structures—that best supports the organization's strategy, capabilities, patient population, and VBC goals. A collaborative structure should solve a strategic need—not simply provide a label or create another layer of complexity.

Deﬁnitions •

•

IPA | An Independent Practice Association is a A network of independent physician practices that collaborates on contracting, administrative services, data, education, or other shared resources while maintaining independent ownership. PHO | A Physician-Hospital Organization is a structure that brings physicians and a hospital or health system together to support coordination, quality improvement, contracting, and other shared activities. CIN | A Clinically Integrated Network is a network of healthcare providers or organizations that uses shared governance, clinical standards, data, quality improvement, and care coordination to improve quality and value and support Value-Based Care arrangements. ACO | An Accountable Care Organization is a group of healthcare providers or organizations collectively accountable for the quality, cost, and overall care of an attributed patient population under a value-based payment arrangement.

Deﬁne What You Need Before considering a delivery structure, identify what your organization is trying to accomplish.

What are we trying to achieve? ☐ Maintain organizational independence ☐ Improve operational efficiency ☐ Strengthen payer contracting ☐ Access shared services ☐ Improve care coordination ☐ Improve quality performance ☐ Strengthen data and analytics capabilities

☐ Access technology/infrastructure ☐ Expand care management capabilities ☐ Increase negotiating/contracting scale ☐ Participate in VBC arrangements ☐ Manage an attributed patient population ☐ Other: ___________________________

Determine Your Desired Level of Independence How important is it for the organization to maintain independent decision-making and operational control?

High Independence We want to • Maintain organizational autonomy • Control our own operations • Build capabilities internally or selectively outsource them Potential ﬁt: Independent Practice © 2026 Synergy 3C – The Clinical Consulting Cooperative, LLC. All Rights Reserved.

Shared Independence We want to • Maintain independence • Collaborate where beneﬁcial • Access Selected shared capabilities • Potentially participate in joint contracting opportunities Potential ﬁt: IPA / PHO

High Collaboration We are willing to • Participate in shared governance • Share data and performance information • Standardize selected processes • Participate in coordinated quality improvement • Leverage extensive shared infrastructure Potential fit: CIN Population Accountability We are prepared to • Manage performance for an attributed population • Participate in VBC contracts • Accept defined accountability for quality and cost Potential fit: ACO

Understand What You Are Signing Up For Before joining or creating a collaborative structure, document: Question

Answer

What services will be provided? What services remain our responsibility? What are the participation requirements? What data must we provide? What quality requirements exist? What ﬁnancial obligations exist? How are shared costs allocated? How are savings/revenues distributed? What governance rights do we have? What performance expectations exist? What happens if we don't meet expectations? How can we exit the arrangement?

Final Recommendation Recommended Delivery Structure ☐ Independent Practice ☐ IPA ☐ PHO ☐ CIN ☐ ACO ☐ Combination / Affiliated Structures

WORD TO THE WISE Choose the structure that supports your strategy—not the strategy that ﬁts the structure.

Why This Choice?

Capabilities This Structure Provides:

Capabilities We Still Need to Develop:

Key Risks If We Make This Choice:

Key Questions Before Proceeding

✱IF YOU REMEMBER NOTHING ELSE…

Don't join a structure simply because everyone else is doing it. Before joining an IPA, PHO, CIN, ACO, or other collaborative arrangement, understand what problem the structure is solving for your organization. Know what capabilities, infrastructure, contracting opportunities, and support you will actually receive—and what will be expected of you in return. A collaborative structure can provide valuable scale and capabilities, but it can also introduce governance requirements, participation expectations, ﬁnancial obligations, and reduced autonomy.

This appendix is referenced in Part III: Selecting the Right Value-Based On-Ramp Notes

Appendix 3: Foundational Capability Evaluation & Planning Tool Purpose

The purpose of this worksheet is to deﬁne the capabilities needed for each payment architecture type. Each different level builds on the capabilities of the previous payment type. In order to be successful in an Advanced Risk model, you would need all the “must-have” capabilities in the lower risk payment types. Instructions: In the last column indicate if you plan to build, buy, or partner on any capability gaps. Payment Architecture Fee-for-Service Plus

Shared Savings

Must-Have Capabilities (Cumulative)

Nice-to-Have Capabilities (Cumulative)

Capability Gap?

Ability to measure and track process and outcome measures

Ability to drill down to patient level and trend progress over time

☐

Evidence-based chronic disease management infrastructure

Multi-disciplinary team to engage patients through outreach and education

Leadership buy-in to VBC principles and physician champion

Training and education program for all staff and new hires

Ability to count patients by payer to understand attribution

Ability to track alignment and quality measures by payer

☐

Ability to risk stratify patients by population and/or disease

Risk stratiﬁcation tool to identify high-needs patients for targeted care

☐

Ability to measure patient engagement at least annually

Ability to electronically capture patient engagement after each encounter

☐

Patient retention strategy (e.g. same-day visits, extended hours, telehealth)

Network participation, provider coalitions to aggregators to improve retention

☐

Increase preventative services (e.g. screenings, AWVs) to improve outcomes

Dedicate outreach program to ensure compliance with screenings and completion of AWVs

☐

Data-driven SMART goals to improve performance

Detailed project plan to identify roles, track progress and ensure accountability

☐

Performance improvement plan to monitor progress and shift initiatives as needed (e.g. PDSA)

Governance team to continuously evaluate and develop new initiatives to meet the objectives of the payment model

☐

Transitional care management program (e.g. Call Us First, Know Where to Go)

ADT feeds and insights into inpatient or ED utilization

Process for assessing and addressing SDOH needs

Partnerships with CBOs and other entities to address SDOH needs

☐

Educational materials for disease process management (e.g. Zone Tools)

Patient portal with links to outside resources for patient education, support groups, and disease management

☐

Financial modeling to determine current cost drivers and risk proﬁle of patient population

Enhanced analytics to measure total cost of care by patient population

☐

Build, Buy, or Partner?

☐

Payment Architecture

Blended Payment Models

Episode-Based or Case-Based Payment

Population-Based Payment

Must-Have Capabilities (Cumulative)

Nice-to-Have Capabilities (Cumulative)

Capability Gap?

Additional staff to manage care coordination and additional touch points between visits

Partnerships with home health, hospice, specialists, or vendors to drive evidence-based care plans

☐

Basic understanding of HCCs and diagnosis coding to the highest speciﬁcity

Focus on moving from CPT-based volume billing to HCC-based riskadjustment payment

☐

Proactive patient outreach and monitoring

AI-driven outreach for patient engagement and care management activities

☐

Care navigation program for speciﬁc patient populations

Disease-speciﬁc care navigation protocols for managing high-cost patients

☐

Financial modeling to determine cost drivers for speciﬁc episodes

Enhance analytics to measure costs at a patient level across all levels of care

☐

Ability to determine post-acute spend patterns

Utilization management program through structured post-acute partnerships

☐

Ability to measure and track readmission rates

Evidence-based care management program to proactively manage patients throughout the episode

☐

Stop-loss insurance or other method of minimizing downside risk

CIN, ACO or other partner to help mitigate risk by sharing services

Comprehensive population health management program

Ability to manage costs across a network of entities and providers

☐

Like-minded referral partners across the spectrum of entities

Downstream risk arrangements with strategic partners

☐

Deep understanding of HCC coding and recapture and ability to track recapture rates

Track HCC recapture rates and provide incentives for higher rates

Audit program to ensure documentation is accurate and supports billing and diagnosis codes Advanced Risk

Advanced ﬁnancial management including actuarial projections and cost analysis

Build, Buy, or Partner?

☐

☐ Actuarial consultant to understand market headwinds and tailwinds

Comprehensive dashboards to track/trend all ﬁnancial and operational metrics

☐

Incentive programs to drive clinical and operational outcomes

Shared-risk arrangements with providers to share in savings and losses

Enhanced care coordination across different care providers (e.g. specialists, hospitals, ASCs, etc.)

Downstream risk arrangements with shared savings and losses

☐

Build, Buy, or Partner Opportunities Remember: You want to start with a few initiatives, then add more as you accomplish your goals. Start Small. Miss Small. Learn big! Instructions: Write down the capabilities you plan to Build internally and use additional appendices to create your pilot project plan. Capability to Build

Planned Start Date

Planned End Date

Instructions: Write down the capabilities you plan to Buy (e.g. technology) and use additional appendices to evaluate the technology and create your pilot project plan. Capability to Buy

Planned Start Date

Planned End Date

Instructions: Write down the capabilities you plan to Share with a Partner and use additional appendices to evaluate the partnership and create your pilot project plan. Capability to Share

Planned Start Date

Planned End Date

✱IF YOU REMEMBER NOTHING ELSE…

Don’t take on more risk than your capabilities can support. Each payment architecture builds on the capabilities of the one before it. Moving toward Advanced Risk is not simply a decision to accept more ﬁnancial risk—it requires the people, processes, data, technology, ﬁnancial management, partnerships, and governance needed to manage that risk successfully. Use this worksheet to identify the capabilities you have today, the gaps that could create risk, and the best approach to close those gaps: Build, Buy, or Partner. Resist the temptation to build everything at once. Prioritize the capabilities that will have the greatest impact on your current payment model and create a foundation for the next level.

Start small. Miss small. Learn big. Then scale what works.

WORD TO THE WISE The goal is not to move into risk quickly—it is to build the capabilities that allow you to succeed when you get there.

This appendix is referenced in Part III: Selecting the Right Value-Based On-Ramp

Appendix 4: Patient Journey Mapping Template Purpose

Identify patient touchpoints, transitions, handoffs, delays, and barriers across the care journey to pinpoint where patients experience friction or fall through the cracks and identify opportunities to improve access, engagement, coordination, quality, and outcomes. Instructions: Read each question carefully and determine if the answer is yes or no. If no, then decide if action is required to achieve a yes. Question

Yes

Is it easy for patients to contact the office either by phone, web or portal? Do patients have to call for an appt. or is there online scheduling through a web portal and are telehealth visits available? Do patients have difficulty parking, have to deal with unpleasant staff or have long wait times either in person or virtually? Are clinical staff members patient, knowledgeable, and caring?

☐

Action Required ☐

☐

Are referrals discussed with patients and instructions given about the referral process? If there are medication or treatment changes, are there written instructions given to the patient? Are patients provided resources (e.g. handouts, websites, support groups) to increase understanding of their disease process(es)? Are patients provided tools to empower them to manage their chronic disease (e.g. medication tracker, BP cuff, scales, symptom tracker, pill box)? Is there a follow up process for referrals to close the loop?

☐

Is there a follow up with the patient to ensure medication understanding, adherence, and effectiveness? Is there a process for following up with a patient after an ED visit or inpatient stay? Is there ongoing communication and monitoring of high-risk patients?

☐

Are patients held accountable for completing wellness visits and/or cancer screenings? Is there a clear process for welcoming and onboarding new patients/newly attributed VBC members? Are patients contacted when they are overdue for recommended visits, screenings, or chronic disease follow-up? Is there a process to identify and outreach to patients who miss or cancel appointments? Are test and diagnostic results reviewed and communicated to patients in a timely manner? Is there a reliable process to ensure patients understand what happens next after each encounter? Can patients easily reach the appropriate person when they have a question or concern after a visit? Is there a process to identify patients who may need additional support due to health literacy, transportation, ﬁnancial, or social barriers?

☐

Question

Yes

Is there a process for following up when a patient does not complete a recommended test, referral, or treatment? Is information from specialists, hospitals, and other providers incorporated into the patient's medical record? Is there a process for following up when a patient does not complete a recommended test, referral, or treatment? Is medication reconciliation completed after transitions of care and when clinically appropriate? Does the practice use patient outreach or technology to support ongoing chronic disease management between visits? Are high-risk patients identiﬁed and assigned an appropriate level of follow-up? Is there a process for escalating patients who demonstrate worsening symptoms, repeated utilization, or other signs of increased risk? Does the practice measure where patients are lost or delayed in the care journey?

☐

Action Required ☐

☐

Patient Journey Gaps Where is the greatest friction for patients?

Where are patients most likely to fall through the cracks?

Which handoffs are most vulnerable to failure?

Which gaps have the greatest potential impact on quality, cost, or patient experience?

Top 3 Opportunities for Improvement: 1. 2. 3.

✱IF YOU REMEMBER NOTHING ELSE…

You cannot improve a patient journey you have not experienced from the patient’s perspective. What may seem like a simple handoff, referral, appointment, or follow-up process to the practice can feel confusing, frustrating, or overwhelming to the patient. The goal is not simply to map what should happen. It is to understand what actually happens to the patient, identify where the experience breaks down, and determine who owns the next step.

WORD TO THE WISE Every handoff is a potential gap, every gap is a potential risk, and every risk is an opportunity to improve the patient experience and outcomes.

This appendix is referenced in Part IV: Building Foundational Capabilities Notes

Appendix 5: Risk Stratiﬁcation Worksheet Purpose This worksheet is designed to help care teams identify priority patients within a value-based care population by combining membership status, visit activity, risk scores, and cost/utilization trends. It is intended to answer a critical VBC question: Are we accurately identifying the patients who need our attention, and does the patient's actual cost of care align with their predicted risk? Instructions: Use this worksheet to prioritize newly attributed patients and those not yet established in care, compare cost trends, identify discordance between cost and RAF/risk scores, and ﬂag opportunities for clinical intervention, documentation improvement, or more accurate risk capture. Population Overview Population

# Members

% of Population

Avg RAF

Total Cost

PMPM

Total Population DSNP CSNP Dual-eligible New members Patients with 2 or more chronic conditions Patients with no visit in 12 months

Priority 1 — New DSNP or CSNP Population Objective Understand the size, characteristics, cost, and engagement of new DSNP/CSNP members. These patients will be the highest priority for outreach and care management. Often newly attributed members have insufficient clinical, utilization, cost, and risk score information to support appropriate stratiﬁcation and care prioritization. Assign a team member to acquire the necessary information from the payer.

Data Sources Needed

Key Principle

☐ Request payer/claims data ☐ Request outside medical records ☐ Medication reconciliation ☐ Review hospital/ED history ☐ Other: __________________

Don't confuse “no data” with “low risk.” When information is incomplete, classify the member as Risk Pending and prioritize obtaining the information needed to appropriately assess and manage the member.

Priority 2 — Current DSNP / CSNP Members With No Visit in 6 Months Objective Identify the size and characteristics of the SNP population that has not had a visit, particularly those with elevated risk or cost. Stratify No-Visit Population Segment

# Members

Avg RAF

Avg Cost

Priority

Low Risk/Low Cost Low Risk/High Cost High Risk/Low Cost High Risk/High Cost

Key Questions How large is the opportunity?

Are high-risk/high-cost members disproportionately represented among those without visits?

What percentage of the no-visit population should receive proactive outreach?

Priority 3 — New Attribution & Visit Engagement Because attribution is changing monthly, track the population as a flow, not just a year-end snapshot. Compare the dual eligible population to the traditional Medicare non-dual and Medicare Advantage populations.

Priority 4 — Cost vs. RAF Alignment This is the core population-level analysis. Objective Determine whether the population's actual cost is generally consistent with its risk profile. # Members

Risk Segment Low RAF (<0.8)

% Population

Avg RAF

Avg Cost

PMPM

Expected Cost*

Variance

Moderate RAF (0.81-1.2) High RAF (1.21-1.5) Very High RAF (>1.51)

*Expected cost should be based on the organization's approved methodology/model. RAF should not be assumed to predict an exact dollar amount by itself.

Population-Level Interpretation High RAF / High Cost → Cost appears directionally consistent with expected risk. High RAF / Low Cost → Potential opportunity for proactive prevention and management before costs increase. Low RAF / High Cost → Priority population for investigation. Low RAF / Low Cost → Generally lower immediate priority; continue routine population management.

What may be contributing to the population-level variance? ☐ New members / insufficient historical data ☐ New attribution ☐ HCCs not captured ☐ Documentation gaps ☐ Coding gaps ☐ Acute events ☐ Hospital / ED utilization

☐ Specialty utilization ☐ Pharmacy costs ☐ Care fragmentation ☐ Social / access barriers ☐ Risk model limitations ☐ Other: _____________________________________________

Most Likely Explanation:

Potential actions to take ☐ Outreach strategy ☐ PCP access intervention ☐ Care management ☐ Workflow redesign ☐ Clinical documentation review ☐ Coding/HCC review ☐ Utilization management

☐ Transitional care intervention ☐ Pharmacy intervention ☐ SDOH intervention ☐ Provider education ☐ Data/analytics investigation ☐ Contract/payer discussion

✱IF YOU REMEMBER NOTHING ELSE…

Don't let risk stratification become a list of high-risk patients. Use it to understand the population. The most valuable insight may not be who is high risk, but where risk, cost, utilization, and engagement are not behaving as expected. Look for the patterns: new DSNP members who have not established care, SNP members without visits, newly attributed members whose costs are rising, populations whose cost is increasing faster than risk, and especially low-risk populations with unexpectedly high costs.

This appendix is referenced in Part IV: Building Foundational Capabilities

Appendix 6: Closed-Loop Referral Process Checklist & Best Practices Purpose Use this checklist to establish a reliable closed-loop referral process that tracks referrals through completion, communicates outcomes to the referring provider, and identiﬁes missed or delayed follow-up that could create gaps in care.

Key Steps in a Closed-Loop Referral  Identify the Need for Referral The referring provider determines that a patient requires specialty care or community services and documents the referral request in the system.  Send and Track the Referral The referral is sent to the appropriate specialist or partner organization. The system logs the referral and tracks its status, ensuring the receiving practice acknowledges receipt.  Confirm Acceptance and Schedule Appointment The receiving provider confirms the referral is appropriate and schedules the patient. Any cancellations, no-shows, or inability to schedule are communicated back to the referring provider.  Patient Completes the Service The patient attends the scheduled appointment or service. The system monitors completion and flags any missed visits for follow-up.  Receive and Document Outcome After the visit, the receiving provider sends a clear, timely consultation note or outcome report to the referring provider. This includes findings, recommendations, and next steps.  Verify and Close the Loop The referring provider confirms receipt of the consultation note. The referral is marked complete in the tracking system, and any follow-up actions are initiated if necessary.  Monitor and Report Metrics Clinics track metrics such as the percentage of referrals closed, no-shows, and cancellations. Reporting helps identify gaps and improve the referral process over time.

Best Practices 1. Bi-directional Communication: Ensure both referring and receiving providers can exchange

information efficiently.

2. Automated Alerts: Use system notiﬁcations to ﬂag incomplete or delayed referrals. 3. Clear Roles and Responsibilities: Assign team members to monitor referrals and follow up on

pending actions.

4. Data Collection: Track outcomes, completion rates, and patient satisfaction to continuously

improve the process.

Use the table below to identify the roles responsible for the Closed-Loop Referral process. Task

Role Responsible

Gap?

Identify the Need for Referral

☐

Send and Track the Referral

☐

Conﬁrm Acceptance and Schedule Appointment

☐

Patient Completes the Service

☐

Task

Role Responsible

Gap?

Receive and Document Outcome

☐

Verify and Close the Loop

☐

Monitor and Report Metrics

☐

Gaps

Build Internally

Strategic Partner

Shared Service

☐

Target Date

✱IF YOU REMEMBER NOTHING ELSE…

A referral is not complete when it is sent—it is complete when the outcome is known and the next step is clear. Assign clear ownership for tracking referrals through scheduling, completion, receipt of results, and follow-up. Technology can support the process, but it does not replace accountability. Track and measure • • • • •

Track referral completion Track time to appointment Track cancellations and no-shows Track results receipt time for consultation results The percentage of referrals that are successfully closed

Use these measures to identify where referrals are getting stuck and determine whether the solution requires a workﬂow change, technology improvement, additional resources, or a stronger partnership with the receiving organization.

WORD TO THE WISE The goal is not to send more referrals. The goal is to ensure patients receive the right care and that the completed referral information comes back to the team responsible for coordinating that care. A referral is only successful when the loop is truly closed.

This appendix is referenced in Part IV: Building Foundational Capabilities Notes:

Appendix 7: Care Transition Mapping Tool Purpose Improving care transitions has been shown to positively affect patient experience scores, and better patient experience has been tied to quicker recovery from illness, better treatment adherence, and higher engagement with care. Instructions: Use this tool to map care transitions across settings, identify gaps and handoff risks, and strengthen post-discharge follow-up to reduce avoidable complications and readmissions

Care Transition Must Do’s: 1. Receive notiﬁcation of patient inpatient discharge If you receive ADT feeds, someone in the practice needs to review these daily. Otherwise, you will need to depend on patients or caregivers to notify the practice of the patient’s discharge. 2. Schedule appointment for follow-up care Ask patient to bring discharge instructions and all medications to the visit. 3. Ensure the patient has received the post-discharge outpatient services and medical equipment This includes labs or imaging, therapy appointments, home health, hospice, cardiac rehab, behavioral health, or DME. 4. Ensure the patient has obtained any new prescribed medications Address medication costs and ability to obtain the medications (transportation). 5. During the transitional care visit  Reconcile patient’s medications  Review discharge instructions with patient  Educate patient about their diagnosis and medications  Review what to do if a problem occurs  Provide educational materials as needed 6. Follow up with patient within seven days to ensure understanding of all instructions Use the table below to identify the roles responsible for the Care Transition process. Not all tasks during the Transitional Care Visit have to be performed by the provider! Task

Role Responsible

Gap?

Receive Notiﬁcation of Inpatient Discharge

☐

Schedule appointment for follow-up care

☐

Ensure the patient has received the post-discharge outpatient services and medical equipment

☐

Ensure the patient has obtained any new prescribed medications

☐

During Transitional Care Visit Reconcile patient’s medications

☐

Review discharge instructions with patient

☐

Educate patient about their diagnosis and medications

☐

Review what to do if a problem occurs

☐

Task

Role Responsible

Provide educational materials as needed

☐

Follow up with patient within seven days to ensure understanding of all instructions Gaps

Gap?

☐

Build Internally

Strategic Partner

Shared Service

☐

Target Date

Notes:

Example:

✱IF YOU REMEMBER NOTHING ELSE…

A hospital discharge begins a critical transition. Establish a reliable process to identify discharges, proactively contact patients, reconcile medications, arrange timely follow-up, and conﬁrm needed prescriptions, services, and equipment are in place. Assign clear responsibility across the care team. Use team members at the top of their roles and licenses, and track patients until transition activities are complete. Measure whether the transition worked - not just whether a follow-up appointment occurred. Monitor medication reconciliation, access to needed medications and services, patient understanding, completed transitions, and avoidable readmissions.

WORD TO THE WISE A patient may leave the hospital with a discharge plan but may not fully understand the plan or have the resources to follow it. A transitional care team helps the patient bridge that gap by ensuring the patient understands what comes next and has the support they need.

This appendix is referenced in Part IV: Building Foundational Capabilities Notes

Appendix 8: Workflow Mapping Template Purpose Use this template to design a new workflow or evaluate and redesign an existing one. Define how work should move across roles, systems, decisions, and handoffs so that ownership is clear and the workflow supports patient care, team performance, and Value-Based Care objectives. For existing workflows, map how work actually happens before redesigning it. For new workflows, begin with the desired outcome and design the process required to achieve it.

1. Identify the Workflow ☐ New Process ☐ Existing Process Being Evaluated/Redesigned Workflow / Process Name Practice Location Process Owner Date Mapped Team Members Involved Workflow Type: ☐ Patient Access / Scheduling ☐ Registration / Check-In ☐ Rooming ☐ Provider Visit ☐ Check-Out

☐ Referral Management ☐ Care Gap Closure ☐ Care Management ☐ Hospital / ED Follow-Up ☐ Medication Management

☐ Patient Outreach ☐ Results Management ☐ Prior Authorization ☐ Acute Triage ☐ Other: ______________________________

2. Deﬁne the Workﬂow Patient Population

Who is included in this workﬂow?

Start Point

What triggers this workﬂow?

End Point

What deﬁnes completion?

Desired Outcome?

What should this workﬂow accomplish?

3. Map the Workflow Existing workflow: Document the process as it occurs today—not how it is supposed to occur. New workflow: Map the proposed process from start to completion. Step/Activity

Owner

System/Tool

Handoff/Next Step

4. Stress-Test the Workflow. Then Evaluate. Consider the workflow from both the patient and care team perspectives. ☐ Are ownership and responsibility clear at every step? ☐ Are handoffs and decision points clearly defined and/or consistent? ☐ Does each role know what action is expected? ☐ Is required information available when needed? ☐ Are there unnecessary steps, duplication, or likely delays? ☐ Could patients experience delays, confusion, or gaps in care? ☐ Does the workflow create unnecessary provider or staff burden? ☐ Does the process depend too heavily on one person? ☐ Can workflow completion and performance be tracked? ☐ Are documentation requirements defined for the workflow?

Gap Analysis: Issue / Design Need

Impact

What Needs to Change?

Priority

5. Final Workﬂow Design Step/Activity

Owner

System/Tool

Handoff/Next Step

Expected Outcome

Next Step: Use the appropriate Playbook tools to implement the workﬂow, assign accountability, establish performance measures, and evaluate results.

✱IF YOU REMEMBER NOTHING ELSE…

A good workflow makes the work clear before the work begins. Define the trigger, outcome, roles, handoffs, decisions, and ownership required to move the patient reliably through the process. When redesigning an existing workflow, map what actually happens—not what the policy says should happen. Workarounds, informal handoffs, duplicate steps, and tribal knowledge often reveal where improvement is needed most.

WORD TO THE WISE Every step requires a clear owner. Unassigned work becomes a gap in care.

This appendix is referenced in Part IV: Building Foundational Capabilities

Appendix 9: Roles, Responsibilities & Accountability Template Purpose The purpose of this template is to take the workflow mapping template and then define responsibility within a specific workflow and establish clear workflow ownership. Workflow: ________________________________________________________________________________ Purpose / Expected Outcome: ____________________________________________________________ Accountable Owner: ___________________________________________________________________ Roles Participating in This Workflow: 1) ________________ 2) ________________ 3) ________________ 4) ________________ 5) ______________ Instructions: Fill in Column 1 with each role within your workflow. In Column 2, define the specific responsibilities, actions, or handoffs assigned to that role within this workflow.

Workﬂow Roles & Responsibilities Role

Accountabilities Within This Workﬂow

Example: [Role]

Describe the speciﬁc steps, actions, or handoffs, each role is responsible for within this workﬂow/process

Handoff Check Where does responsibility transfer between roles?

Are any workﬂow steps missing an assigned role? ☐ No ☐ Yes: If yes, describe missing steps:

Are any responsibilities duplicated or unclear? ☐ No ☐ Yes: If yes, describe:

WORD TO THE WISE Deﬁne responsibility within the workﬂow, not by the job title alone.

This appendix is referenced in Part IV: Building Foundational Capabilities

100

Appendix 10: Strategic Partnership & Shared Service Evaluation Tool Purpose Use this tool to evaluate strategic partners and shared-service options for ﬁnancial, operational, clinical, and cultural ﬁt. Engage the leaders and team members who will use, manage, or be affected by the partnership in the evaluation and selection process.

Vendor Selection Planning Worksheet Section A: Problem Identiﬁcation Clearly state the gap or problem to be solved (e.g. improve HCC capture, improve quality performance, care coordination/navigation or reduce staffing burden)

Section B: Describe the goals and/or expected outcomes for this vendor

Section C: Describe the success metrics for this vendor Financial: Operational: Clinical: Patient Experience: Workforce: Section D: Describe the internal barriers or considerations that will need to be evaluated Budget: Timeline: Staffing: Technology: Compliance:

Vendor Inventory Worksheets Instructions: Score each vendor from 1 (poor) to 5 (excellent) on each of your prioritized items, and rank priorities as low, medium or high. Total the ratings for each vendor to make your comparisons. Assign priorities as low, medium, or high depending on current needs. NOTE: There are multiple vendor types represented in this table. All Vendors

Criteria

Priority

Vendor A

Vendor B

Vendor C

Do they have signiﬁcant health care experience? Do they have rural health experience? Do they have VBC expertise? Do they have demonstrated outcomes? Are the outcomes published or anecdotal? © 2026 Synergy 3C – The Clinical Consulting Cooperative, LLC. All Rights Reserved.

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Criteria

Do they have a detailed Implementation/onboarding approach? Can they demonstrate a positive return on investment (ROI)? Is their pricing transparent? Is the upfront cost comparable? Are there ongoing licensing and/or maintenance costs? Does their culture and communication style align with our organization? Does the organization have strong ethical guidelines, commitments, and priorities? Do they have excellent ongoing support and customer service? Are workflows or processes customizable? Is customer support available 24/7? Do they have a clinical escalation process? Is it easy to collaborate with the vendor? Are they willing to take on risk for success or failures? Do they manage exceptions or service interruptions timely? Do they have a track record of sustaining client relationships? Are they financially healthy and able to ensure continuity of service delivery and avoid disruptions? Do they have a robust compliance program? Technology Vendors Will this integrate into current workflows? Do they have easy-to-access reports or dashboards to track metrics or outcomes? Is the application easy to use or is a lot of training required? Is the application cloud-based? Are there technology license requirements? Does it adhere to the required industry standards & regulations (e.g. HIPAA, SOC 2, HITRUST, ISO, etc.)? Do they have environmental, social, and governance policies in place? Are they able to adapt and innovate quickly? Do they have industry expertise that adds value? Clinical or Shared Service Vendors Do they credential their clinicians per license requirements? Do they perform annual licensure and OIG checks? Do clinicians practice at the top of their license? Do they have an annual compliance training (HIPAA, fraud/waste/abuse, ethics, etc.) requirement for all staff? If non-clinical staff are utilized, are background checks performed annually? Will they be given access to your EHR? Do they use evidence-based criteria is managing chronic conditions?

Priority

Vendor A

Vendor B

Vendor C

102

Criteria

Do they have the capability to deliver virtual monitoring, digital interventions, and care coordination tools to meet performance targets? Do their systems integrate with your EHR? Are they able to support audits by CMS or other regulators? Do they have a strong process for incident reporting? Do they have patient safety protocols and crisis response plans? Are they able to adapt to evolving care models and beneﬁciary needs? Are they able to handle large, diverse patient populations? Are their performance metrics tied to outcomes and not just service delivery? Can they deliver continuous, longitudinal care beyond episodic visits? Can they provide transparent reporting of interventions and outcomes? Will there be a single point of contact or will you have access to individual clinicians? Are there protocols, call scripts, etc. customizable to your practice needs?

Priority

Vendor A

Vendor B

Vendor C

**EHR speciﬁc Vendors** As you weigh the pros and cons of your electronic health record (EHR) vendors, you may ﬁnd it difficult to remember all the features and capabilities of each system. This template allows you to keep track of critical features. Score each vendor from 1 (poor) to 5 (excellent) and rank priorities as low, medium, or high.

Functionality/Usability

Priority

Vendor A

Vendor B

Vendor C

EHR Vendors Can the system accommodate and potentially improve my workﬂow? Can I easily build and/or customize “off-the-shelf” templates? Does the system offer a variety of data entry options (e.g. dictation, voice recognition, AI scribe, structured notes)? Does the system alert me about unﬁnished portions of clinical documentation? Can I easily access other clinical information (e.g. previous labs, progress notes, etc.) from a patient’s record while charting? Does the system allow me to multi-task (e.g. create tasks, order labs, review medications, etc.) while charting? Does the system allow me to forward patient information to staff, other physicians, etc. via e-mail, fax, or messaging? Does the system ensure that only authorized clinicians can sign clinical documentation? Can I complete a prescription, lab order, or referral within a few clicks and send electronically? © 2026 Synergy 3C – The Clinical Consulting Cooperative, LLC. All Rights Reserved.

103

Functionality/Usability

Priority

Vendor A

Vendor B

Vendor C

Can I look up medication information such as drug interactions easily and is this information valuable? Can the system handle multiple drug formularies? Does the system notify me of abnormal lab results and provide normal ranges? Can I create and/or customize “off-the-shelf” order sets? Does the system utilize clinical information from all parts of the record to provide decision support? Does the system alert me when patient data indicates intervention is recommended? How disruptive are the alerts? Are they customizable and can they be overridden? Can I access medical literature, clinical guidelines, etc. within the system? Can I query the system and identify patients that have a particular condition or are on a certain medication, etc.? Does the system track patients for follow-up and send out reminders? Does the system provide a summary view of a patient’s health status? Can I create ad-hoc reports or am I limited to ones provided off-the-shelf? Can I customize the off-the-shelf reports? Are there population-based dashboards to manage speciﬁc populations (e.g. disease-speciﬁc, risk level, payer, etc.) Does the system track quality measures and/or care gaps? Can I look up a patient by different criteria such as DOB, medical record number, social security number, etc.? Does the system provide a summary view of a patient’s health status? Does the system alert me of overdue tasks and urgent lab results? What are the technology license requirements? Does it adhere to the required industry standards & regulations (e.g. HIPAA, SOC 2, HITRUST, ISO, etc.)? Does the vendor have environmental, social, and governance policies in place? Do they have industry expertise that adds value?

Final Recommendation Recommended Vendor Reason for Selection Key Strengths Risks Accepted

104

✱IF YOU REMEMBER NOTHING ELSE…

The right partner should extend your capabilities—not create another problem to manage. Evaluate fit beyond the product and price, including your strategy, workflows, clinical standards, financial realities, and patient-care expectations. Define the problem and expected outcomes before selecting a partner. Look for demonstrated results, implementation experience, strong references, reliable support, compliance, and financial stability. Be explicit about what the partner owns, what your organization owns, and how success will be measured. A strong partner shares accountability for outcomes, not simply responsibility for delivering a service.

WORD TO THE WISE You are not just selecting a vendor—you are selecting an extension of your organization. Choose a partner whose success depends on your success.

This appendix is referenced in Part IV: Building Foundational Capabilities Notes

105

Appendix 11: Technology Inventory Worksheet Purpose The Technology Inventory Worksheet provides a structured assessment of the technology currently available to the practice and identiﬁes gaps that may affect its ability to successfully implement and sustain Value-Based Care. Use this tool to inventory what technology your organization has, how it is being used, whether systems can communicate with one another, and where additional capabilities may be needed.

1. Practice Technology Inventory Technology / System

Vendor / Platform

Currently Used?

Primary Purpose

VBC Capability Supported

Meets Needs?

EHR

☐ Yes ☐ No

Practice Management System Patient Portal

☐ Yes ☐ No

Telehealth

☐ Yes ☐ No ☐ Yes ☐ No

HIE / Data Exchange

☐ Yes ☐ No

Population Health Platform Analytics / Reporting

☐ Yes ☐ No

Care Management

☐ Yes ☐ No ☐ Yes ☐ No

Referral Management

☐ Yes ☐ No

e-Prescribing

☐ Yes ☐ No

Remote Patient Monitoring

☐ Yes ☐ No

Patient Communication / Outreach Other _________________

☐ Yes ☐ No

2. Technology Capability Assessment Rate each capability:

1 = Not Available

Capability EHR functionality Patient portal Patient access / scheduling Telehealth Clinical data exchange Claims / utilization data Population health analytics Quality reporting Care gap identiﬁcation Risk stratiﬁcation Care management Referral tracking Patient outreach Remote monitoring Reporting / dashboards

1 ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

2 = Limited 2 ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

3 ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

3 = Adequate 4 ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

4 = Strong Gap / Opportunity

106

3. Interoperability & Data Flow Can the practice electronically exchange information with… Data Source / Partner Payers Hospitals Specialists Pharmacies HIE

Yes ☐ ☐ ☐ ☐ ☐

No ☐ ☐ ☐ ☐ ☐

Limited ☐ ☐ ☐ ☐ ☐

ACO / CIN / IPA Patients

☐ ☐

Notes

Key Questions • Can the practice receive timely claims and utilization information? • Can hospital and ED notiﬁcations be received? • Can specialist records be obtained electronically? • Can data be incorporated into the workﬂow? • Are staff able to access the information when they need it?

4. VBC Technology Readiness VBC Requirement Identify attributed population Identify care gaps Risk stratify population Monitor quality measures Track utilization Monitor cost Track referrals Monitor transitions of care Conduct patient outreach Monitor VBC performance

Technology Supports It? ☐ Yes ☐ No

Gap Identified? ☐

☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No

☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

Action Needed

Overall Technology Readiness ☐ Ready — Technology supports current VBC needs ☐ Ready With Gaps — Core technology exists, but improvements are needed ☐ Needs Development — Signiﬁcant technology capabilities are missing ☐ Not Ready — Technology limitations may prevent successful VBC implementation Top 3 Technology Priorities

1. 2. 3.

107

WORD TO THE WISE Technology should enable the VBC workﬂow—not create another workﬂow.

✱IF YOU REMEMBER NOTHING ELSE…

Before purchasing another platform, understand what the practice already has, what it can actually do, and whether existing systems can share information. The most expensive technology is not necessarily the most useful. Prioritize technology that puts actionable information in front of the right person at the right time and supports the work the practice is already expected to do.

This appendix is referenced in Part IV: Building Foundational Capabilities Notes

108

Appendix 12: Interoperability Planning Checklist Purpose Interoperability is crucial because it enables different systems, applications, and organizations to seamlessly exchange and use data improving efficiency, collaboration, and decision-making. This appendix provides a concise, practical interoperability planning checklist to prepare for U.S. interoperability mandates.

Deﬁnitions ONC – Office of the National Coordinator for Health Information Technology. The ONC leads and coordinates interoperability activities nationwide. TEFCA – The Trusted Exchange Framework and Common Agreement serves to bring disparate, disconnected networks of information together, in a coordinated way, to better enable care and secure patient access to their own data. USDCI – The United States Core Data for Interoperability is a standardized set of health data classes and constituent data elements for nationwide, interoperable health information exchange. FHIR – Fast Healthcare Interoperability Resources deﬁnes a set of standardized data types (resources) for exchanging healthcare information in a structured, interoperable way. API – An Application Programming Interface is a set of rules, protocols, and tools that allow different software applications to communicate with each other.

Key Benefits of Interoperability Efficient Data Sharing: Interoperable systems allow data to flow freely between different platforms without manual intervention, reducing the need for data reformatting or duplication and preventing data silos. For example, in healthcare, interoperability enables clinicians to access lab results and historical patient records from multiple systems to make informed decisions. Enhanced Collaboration: By connecting diverse systems, interoperability improves communication and coordination across departments, organizations, or even industries. Teams can work with a unified view of data, which fosters collaboration and reduces errors caused by inconsistent information. Operational Efficiency: Interoperability accelerates workflows by eliminating time-consuming tasks such as manual data entry and processing. Users can focus on core tasks rather than preparing or correcting imported data, which increases productivity and reduces operational costs. Business Agility and Competitive Advantage: Organizations that adopt interoperable systems can integrate new tools and technologies more easily, adapt to changing market conditions, and scale operations efficiently. Companies that fail to embrace interoperability risk being trapped in proprietary silos, limiting growth and innovation. Regulatory and Standard Compliance: Interoperability often relies on common standards for data exchange, which can help organizations comply with industry regulations and maintain consistent practices across systems.

109

Adoption Timeline: Timeline

Workﬂow

Month 1

Assess Current Systems & Applications

Months 2-3

Align with Standards

Months 3-4

Data Governance & Security

Months 4-5

Workﬂow Integration

Months 5-6

Testing & Validation

Ongoing

Monitoring & Optimization

Tasks

Inventory all systems and data flows Identify non-compliant interfaces Map current vs. required USCDI v6 elements Upgrade to FHIR R5 APIs Configure USCDI v6 data sets Consider joining a Qualified Health Information Network (QHIN) or connect via a participating intermediary to comply with TEFCA Establish clear policies for data ownership, consent, and data sharing Strengthen HIPAA compliance with encryption, audit logs, and role-based access Embed interoperability features into clinical workflows to avoid disruption Train staff on access and sharing external patient data Conduct end-to-end data exchange tests with parter organizations Validate data accuracy, timelines, and completeness Set KPIs for interoperability performance (e.g. response time, data match rate) Schedule quarterly reviews to adapt to evolving ONC guidance

✱IF YOU REMEMBER NOTHING ELSE…

True interoperability means getting the right information to the right person, in the right format, at the right time. Define what data needs to be exchanged, why it is needed, and how it will be used. Make sure your systems, workflows, vendors, and data-sharing agreements can support the exchange. Choose flexible, standards-based solutions that can adapt as requirements evolve. Most importantly, test the data in the real-world workflow. A technically successful interface is not necessarily a clinically successful one. If information is incomplete, late, difficult to find, or creates additional work for staff, you have connectivity—not effective interoperability.

WORD TO THE WISE Interoperability is successful when information moves seamlessly—and people can use it to make better decisions, deliver better care, and achieve better outcomes.

This appendix is referenced in Part IV: Building Foundational Capabilities Notes

110

Appendix 13: Data Governance Checklist Purpose The purpose of this checklist is to assist organizations with establishing and maintaining a successful data governance program to help ensure the quality of data and conﬁdentiality of patient records.

Key considerations for data governance: • •

Accuracy Completeness

• •

Consistency Timeliness

• •

Policies and Procedures Structure

Consideration

Yes

Critical Gap?

☐

☐ ☐

☐

☐ ☐

☐ ☐ ☐

☐

Accuracy

Do we have automated validation tools to detect and ﬂag potential errors in patient and member records? How frequently do we audit data, and what is the error rate? What training do staff members receive on proper data entry protocols?

Completeness What percentage of our patient records contain all required data ﬁelds? How do we identify and address incomplete records? How do we consolidate data from disparate sources for a comprehensive view of the patient?

Consistency

How do we ensure information remains consistent across different sources and systems across the healthcare ecosystem? Have we standardized data formats and data entry protocols across the organization? What reconciliation processes do we use to identify and resolve data discrepancies?

Timeliness How quickly is data available to support decision-making? How frequently are we cleansing and validating rapidly changing data? What technology solutions are we using to reduce delays in data availability?

Structure

Do we have an organizational structure with roles and responsibilities at various levels to manage data? Do we have a designated data steward responsible for coordinating data governance activities? Do data stewards have the authority to quickly and efficiently correct data problems while still ensuring access to patient records?

Policies & Procedures

Do we have policies and procedures in place to ensure that all data are collected, managed, stored, transmitted, used, reported, and destroyed in a way that preserves privacy and ensures conﬁdentiality and security? Do we have a written plan outlining processes for monitoring compliance with the established policies and procedures? Have data governance policies and procedures been documented and communicated in an open and accessible way to all stakeholders including staff?

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Critical Governance Gaps

Build Internally

Strategic Partner

Shared Service

☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

Target Date

✱IF YOU REMEMBER NOTHING ELSE…

If you cannot trust your data, you cannot trust the decisions you make with it. Establish clear ownership for data quality, deﬁnitions, access, and maintenance. Make sure teams are working from consistent deﬁnitions and know who is responsible when data is incomplete, inaccurate, or inconsistent. Data governance is ongoing work. Review data quality routinely, resolve issues at the source, and maintain clear standards as systems, measures, and reporting requirements change.

This appendix is referenced in Part IV: Building Foundational Capabilities Notes

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Appendix 14: Value-Based Care Contract Evaluation Guide Purpose Use this guide to determine what a proposed Value-Based Care contract will required of your organization and whether you have the capabilities to perform successfully.

Important Note: Use appropriate legal, ﬁnancial, actuarial, compliance, and contracting expertise before executing any Value-Based Care agreement.

1. Know the Opportunity Contract Element Payer: Contract/Program: Population: Estimated Attributed Lives: Performance Period:

Information

☐ Does the opportunity align with our VBC strategy/goals? ☐ Does the population align with our clinical capabilities? ☐ Is the opportunity meaningful enough to justify the required investment? ☐ Are we prepared for the proposed level of accountability?

Strategic Fit: ☐ Strong ☐ Moderate

☐ Weak

2. Know Who You Are Accountable For We Can Clearly Deﬁne

Yes

Which patients are attributed to us How patients are attributed When attribution can change Important eligibility and inclusion / exclusion rules How attribution changes affect performance

☐ ☐ ☐ ☐ ☐

No/ Unclear ☐ ☐ ☐ ☐ ☐

Bottom line: Do we know exactly which patients we are expected to manage and be accountable for?

3. Understand the Financial Model Contract Element Payment methodology Benchmarks / targets Shared savings / incentive Downside risk, if applicable Quality gate Risk corridor / cap, if applicable Withold, if applicable Reconciliation / payment timing

Deﬁned & Understood?

Questions/Concerns

☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

Key Question: Can we explain how clinical and quality performance becomes ﬁnancial performance under this contract?

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4. Know the Quality & Performance Requirements ☐ We know which quality and performance measures apply. ☐ We know the required targets/benchmarks. ☐ We know our current performance against them. ☐ We can inﬂuence the measures for which we are accountable. ☐ We can monitor performance during the contract year. ☐ We understand how quality affects payment.

Capability Gap: ___________________________________________________________________________________

5. Know What Data You Will Need ☐ Will we know which patients are attributed to us? ☐ Will we receive timely patient-level performance data? ☐ Will we have the claims / utilization data needed to manage the population? ☐ Can we integrate or operationalize payer data? ☐ Can we monitor performance throughout the year? ☐ Can we identify and resolve data discrepancies? Key question: Can our teams get the information they need in time to act on it?

6. Determine What You Must Be Able to Do Required Capability

Ready

Care management Care coordination Patient outreach / engagement Chronic condition management Care gap closure Transitional care management Medication management Referral management SDOH / resource support Quality measurement / reporting Data / analytics Other:

☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

Needs Strengthening ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

Partner/Shared Service ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

What will providers and staff need to do differently?

Are roles, workﬂows, and accountability deﬁned? ☐ Yes ☐ No ☐ Needs further evaluation

7. Understand the Risk Potential Exposure Maximum ﬁnancial exposure Population / attribution changes Quality performance Data limitations Staffing / capacity Utilization outside our control

Understood? ☐ ☐ ☐ ☐ ☐ ☐

Concern? ☐ ☐ ☐ ☐ ☐ ☐

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8. Identify the Investment Required Capability Investment Needed Workforce Technology Data / analytics Workﬂow redesign Training / change management Partner / shared services

Before Launch? ☐ ☐ ☐ ☐ ☐ ☐

Plan in place (e.g. workaround)? ☐ ☐ ☐ ☐ ☐ ☐

Is the expected opportunity sufficient to justify the required investment? ☐ Yes ☐ No ☐ Unclear

9. Are We Ready to Perform? Before moving forward, can leadership answer yes? ☐ We know who and what we are accountable for. ☐ We know how performance will be measured. ☐ We know how performance affects payment. ☐ We know our maximum financial exposure. ☐ We will have timely data to manage performance. ☐ We have—or have a plan to build or access—the capabilities required to perform. ☐ Our providers and teams are prepared to execute the model. ☐ The expected opportunity justifies the investment and risk. ☐ Appropriate legal, financial, actuarial, compliance, and contracting review has occurred.

Overall Readiness: ☐ Ready to Move Forward ☐ Move Forward After Identiﬁed Gaps Are Addressed Capabilities that must be strengthened before moving forward:

☐ Not Ready

1. 2. 3.

✱IF YOU REMEMBER NOTHING ELSE…

A Value-Based Care contract tells you what you are accountable for. Your capabilities determine whether you can deliver. What are we being asked to deliver? What capabilities will it require? Can we reliably perform?

WORD TO THE WISE Make sure you can perform BEFORE you sign.

This appendix is referenced in Part IV: Building Foundational Capabilities Notes

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Appendix 15: Financial Modeling & ROI Worksheet Purpose: Use this worksheet to estimate the ﬁnancial opportunity, required investment, potential exposure, and expected return of a Value-Based Care initiative. The goal is to test whether the ﬁnancial opportunity is sustainable and identify the assumptions and capabilities that must be in place for the model to work.

1. Define the Opportunity Start by defining the financial opportunity you are evaluating. Identify the population, payment model, and performance period so that revenue, costs, and expected return are evaluated against the same opportunity. Opportunity Payer / Program Patient Population Estimated Attributed Members Contract / Payment Type Performance Period

Information

What ﬁnancial opportunity are we evaluating?

2. Estimate the Financial Opportunity Identify the financial benefits the initiative could reasonably generate. Base estimates on known contract terms and realistic performance assumptions rather than the maximum possible upside. Potential Financial Benefit Care management / PMPM payments Quality / performance incentives Shared savings Other incremental revenue Avoided or reduced costs, if applicable Total Expected Financial Benefit

Key Assumptions

$ $ $ $ $ $

Estimated amount

What assumptions have the greatest impact on the expected ﬁnancial beneﬁt?

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3. Know What It Will Cost to Perform Estimate the resources required to deliver the performance the ﬁnancial model assumes. Include existing resources that must be expanded or redirected, as well as new investments and external support. Investment / Cost Workforce / staffing Technology Data / analytics / reporting Care management / clinical operations Training / change management Patient engagement Other Total Estimated Investment

Existing Resource, New Investment, or Partner?

Estimated Cost $ $ $ $ $ $ $ $

Which investments are required before performance begins?

4. Estimate the Return Compare the expected financial benefit with the investment required to generate it. Determine the expected net benefit, ROI, and break-even point before deciding whether the opportunity warrants further investment. Financial Measure Total Expected Financial Benefit Total Estimated Investment / Cost Expected Net Financial Benefit Estimated ROI

Estimate $ $ $ $

Net Financial Benefit = Financial Benefit – Total Cost Use incremental financial benefit and incremental costs associated with the VBC initiative. Simple ROI Calculator A. B. C. D.

Total Expected Financial Beneﬁt Total Estimated Investment / Cost Net Financial Beneﬁt ( A – B) ROI (C / B) X 100

Amount $ $ $ %

Estimated break-even point: $_____________ What level of patient volume, performance, or savings must be achieved to break even?

Example: Expected financial benefit = $150,000 Investment = $100,000 Net financial benefit = $ 50,000 ROI = $50,000 / $100,000 X 100 = 50%

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5. Test Your Financial Assumptions Identify the assumptions that have the greatest influence on expected financial performance. Test how changes in those assumptions could affect the return and whether the financial model remains viable if performance falls short. Key Financial Driver Attributed patient volume Patient engagement / participation Quality Performance Utilization / Cost performance Incentive / shared savings earned Implementation / operating costs Other:

Out Assumption

What if We Fall Short?

Which assumptions have the greatest impact on ﬁnancial performance?

How much variation can the ﬁnancial model absorb before the initiative is no longer ﬁnancially viable?

6. Consider Financial Exposure Identify where the organization could experience ﬁnancial loss or underperformance. Understand the potential exposure and whether the organization has the ﬁnancial and operational capacity to manage it. Financial Exposure Patient volume /attribution Utilization / medical cost Quality performance Risk adjustment Operational capacity Contractual downside risk

Understood?

Concern?

Maximum potential ﬁnancial exposure: $______________ Can the organization absorb the exposure if performance falls short?

7. Look Beyond the Financial Return Consider the broader value these investments may create. Some investments strengthen capabilities, outcomes, experience, or infrastructure that create value beyond the immediate ﬁnancial return and support future Value-Based Care opportunities.

What additional value could the needed investments create? ☐ Improved patient outcomes ☐ Improved patient experience ☐ Improved provider / staff experience ☐ Reduced avoidable utilization ☐ Improved quality performance

☐ Stronger care coordination ☐ Improved operational efficiency ☐ Capabilities that support additional VBC opportunities ☐ Other: __________________________________________

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8. Financial Readiness Bring the ﬁnancial analysis together before moving forward. Leadership should be able to explain the opportunity, required investment, key assumptions, potential exposure, and expected return—and identify what still needs to be resolved.

Before moving forward, can leadership answer yes? ☐ We understand the expected financial opportunity. ☐ We know what it will cost to perform. ☐ We have identified the assumptions driving the financial model. ☐ We have tested what happens if performance falls short. ☐ We understand our maximum financial exposure. ☐ We know which capabilities require investment before launch. ☐ The expected return justifies the required investment and risk.

Overall Financial Readiness: ☐ Financially Viable ☐ Potentially Viable - Additional Work Required ☐ Further Modeling Needed ☐ Not Currently Viable

What must be resolved before moving forward? 1. 2. 3.

✱IF YOU REMEMBER NOTHING ELSE… Don't confuse revenue with ROI. A VBC contract can generate additional revenue and still produce a negative return if the organization underestimates the people, technology, infrastructure, care management, reporting, and operational resources required to achieve the results. Know what you will have to invest, test your assumptions, and determine what happens if performance falls short.

WORD TO THE WISE Know your break-even point before you sign the contract and know what has to work operationally to reach it.

This appendix is referenced in Part IV: Building Foundational Capabilities Notes

119

Appendix 16: Core Value-Based Care Metrics Dashboard Purpose Dashboards help organizations easily visualize key performance indicators that measure clinical quality, cost efficiency, patient satisfaction, and care coordination. These metrics help providers meet quality benchmarks, reduce costs, and improve patient outcomes.

Patient Outcome Metrics •

Readmission rates – Percent of patients readmitted within 30 days of discharge from an inpatient facility

•

Chronic disease control – Examples include HbA1c control for diabetes or blood pressure control for hypertension

•

Timely transitional care rates – Percent of transitional care visits that occur within 14 days of discharge from an inpatient facility

Cost Metrics •

Cost per episode of care – Total cost divided by number of cases for a speciﬁc condition or procedure

•

Avoidable ED visits (ED/K) – Percent of ED visits for non-urgent or emergent issues

•

Avoidable admissions for patients with chronic conditions (AD/K) – Percent of patients with chronic conditions that are hospitalized with exacerbations of that disease

•

Per-member, per month (PMPM) – Total cost per enrolled member or beneﬁciary

Patient Satisfaction and Engagement •

Survey results (net promoter score) – Patient-reported satisfaction in communication, service and overall care

•

Missed visit rates – Percent of patients who fail to complete scheduled visits

Care Coordination and Prevention •

Preventative care compliance – Vaccination rates and cancer screening completed

•

Care transitions – closed-loop percentage on all referrals

•

Social determinants of health integration – SDOH screening on all patients and resources/referrals provided to meet needs

•

Anxiety/depression screening – Percent of patients screened for anxiety and/or depression

Dashboard Design Tips •

Visual trends over time versus a single point in time using monthly data

•

Compare your numbers against national averages or payer requirements

•

Highlight high-risk patients using risk stratiﬁcation tools

•

Integrate real-time data from EHR, claims, and patient feedback platforms

•

Allow drill-down to clinic, provider or patient level detail

120

Example of a Provider Scorecard:

Phil Better, MD

✱IF YOU REMEMBER NOTHING ELSE…

A dashboard should tell you where to look, why it matters, and what to do next. The purpose of a Value-Based Care dashboard is not to create more reports—it is to turn data into actionable insight. The most useful dashboards connect clinical quality, cost, patient experience, prevention, and care coordination so the organization can see how these measures influence one another. Focus on trends, not snapshots. A single number tells you where you are; a trend tells you where you are going. Compare performance to meaningful benchmarks, identify variation, and drill down when necessary to understand which patients, providers, workflows, or populations are driving the results. Keep the dashboard focused on the measures that matter most. Too many metrics can create noise and make it difficult to recognize the signals that require attention. Every important measure should have a clear owner and a defined response when performance falls outside the expected range.

WORD TO THE WISE Data does not improve care—people do. The dashboard's job is to help the right people see the right information early enough to make a difference.

This appendix is referenced in Part IV: Building Foundational Capabilities

121

Appendix 17: Performance Improvement Drivers Purpose: A ﬁshbone diagram is a simple tool that can be used to identify drivers to success or identify the root cause of an issue or capability gap. Below are examples of success drivers for VBC goals. Other diagrams can be built after doing a Root Cause Analysis (Appendix 31) for the issue to be resolved. Fishbone Diagrams are GREAT exercises for teams!

122

123

124

Appendix 18: Performance Improvement Action Plan Purpose Whether you are creating improvement activities for speciﬁc performance measures, outcome measures, or compliance issues, you can use this template to create your plan of attack to meet your goals. For a more robust plan, use Appendix 27: Minimum Viable Pilot (MVP) Planning Worksheet. The goal is to create a closed-loop improvement process that allows the organization to test interventions, measure results, adjust strategies, and sustain improvements over time.

Action Plan Improvement Activity (Priority)

Intervention

Owner

Start Date

Target Date

Measure

Status

Escalation Identify issues that require leadership, payer, compliance, or other organizational review. Issue

Reason for Escalation

Escalated to

Date

Resolution

Escalation Triggers ☐ Significant patient safety concern ☐ Repeated quality failure ☐ Regulatory/compliance concern ☐ Significant financial/VBC impact ☐ System-wide issue

☐ Resource constraint ☐ Provider performance concern ☐ Technology/data issue ☐ Other: __________________

WORD TO THE WISE A performance improvement plan is only as effective as the accountability behind it. Don't create an action plan simply to document a problem. Deﬁne who will do what, by when, and how you will know it worked. Monitor progress regularly and be willing to change the intervention when the data shows it isn't working.

This appendix is referenced in Part IV: Building Foundational Capabilities

125

Appendix 19: Quality Assurance / Performance Improvement Committee Template Purpose Use this template to establish a practical Quality Assurance Committee process for reviewing quality, patient safety, compliance, Value-Based Care performance, and organizational improvement; identifying issues that require action; assigning accountability; and verifying improvement. Regulatory Considerations Quality oversight requirements vary by practice type, certification status, payer contracts, accreditation, and applicable federal and state requirements. Practices should confirm the requirements that apply to their organization and adapt this committee structure accordingly. For Medicare-certified Rural Health Clinics (RHCs), 42 CFR Part 491 establishes federal Conditions for Certification. CMS survey and compliance guidance for RHCs is available in the State Operations Manual, Appendix G. The committee structure and process in this template are recommended practices and should not be interpreted as a universal CMS-prescribed committee model. Reference: 42 CFR Part 491; CMS State Operations Manual, Appendix G – Rural Health Clinic Survey Protocol; CMS RHC Information Center.

CMS Rural Health Clinic Conditions for Certiﬁcation and FQHC Conditions for Coverage

1. Committee Structure Establish who participates in the committee, who leads it, when it meets, and the performance period under review. Include representation required by the practice's regulatory, contractual, accreditation, or governance requirements. Committee Information

Details

Practice Meeting Date Performance Period Reviewed Committee Chair Clinical Lead Committee Members Required Representation, if applicable Meeting Frequency

☐ Monthly

☐ Quarterly

☐ Other:

2. Standing QA Review Use a consistent agenda to review the areas most important to clinical quality, patient safety, compliance, ValueBased Care performance, and organizational improvement. Select the areas relevant to your practice. Standing Review Areas ☐Prior action items ☐ Patient safety ☐ Regulatory and contractual compliance ☐ Patient access and experience ☐Medication safety ☐ New or emerging concerns

☐ Clinical quality and care gaps ☐ VBC performance and utilization ☐ Documentation and coding integrity ☐ Referrals and care coordination ☐ Operational issues affecting quality ☐ Other:

Begin each meeting by reviewing open action items from the prior meeting and determining whether the intended improvement occurred. Bring the appropriate dashboards, reports, patient-safety information, complaints/grievances, or other performance data to the meeting rather than reproducing them in this template.

126

3. Findings Requiring Attention Focus committee discussion on performance that is below target, declining, creating patient-safety or compliance risk, or otherwise requires intervention. Issue / Finding

Evidence / Performance Gap

Priority ☐ H ☐M ☐ L ☐ H ☐M ☐ L

Further Analysis Needed? ☐ Yes ☐ No ☐ Yes ☐ No

For each signiﬁcant ﬁnding, ask • • •

What is happening? Why is it happening? Is the issue isolated or systemic?

• •

Does the issue require formal Root Cause Analysis? What needs to change

4. Actions & Accountability Translate ﬁndings into action. Assign ownership, establish a completion date, and determine how the committee will know whether the intervention worked. Action / Improvement

Owner

Due Date

Measure of Improvement

Status

Escalation or formal improvement work required? ☐ Yes ☐ No If yes, use the Root Cause Analysis Template and/or Improvement Action Plan.

5. Close the Loop Before ending the meeting, conﬁrm key decision, rationale, ownership, and what must be reviewed at the next meeting. Close-Out Item Key Decisions / Rationale / Escalations Items Carried Forward Next Meeting / Review Date Data or Results to Review

Notes

✱IF YOU REMEMBER NOTHING ELSE…

A Quality Assurance Committee should not become a meeting where data is reviewed and nothing changes. The value of the committee is in moving from measurement → insight → action → accountability → improvement. Focus on the issues that matter most. When performance falls short, determine why, assign ownership, take action, and verify improvement.

WORD TO THE WISE If the same problem appears on the agenda three meetings in a row without an action or improvement, the process—not just the performance—needs attention.

This appendix is referenced in Part IV: Building Foundational Capabilities

127

Appendix 20: Compliance Requirement Checklist Purpose This checklist provides a simple framework for assessing whether a primary care practice has the foundational compliance policies, processes, and safeguards needed to operate effectively in a value-based care environment. Use this checklist to identify compliance requirements that are in place, need attention, or require further review before implementing or expanding VBC activities. Note: This checklist is a high-level operational tool and is not intended to replace legal or compliance counsel. Requirements may vary based on the practice, payer contracts, patient population, state, and applicable federal and state regulations.

Compliance Checklist Compliance Requirement

HIPAA Privacy & Security

HIPAA policies & procedures are current Workforce HIPAA training is completed Patient information is appropriately protected Access to electronic health information is controlled Patient Rights Patient complaints/grievances have a defined process Documentation & Medical Records Medical records are complete and maintained appropriately Clinical documentation supports services provided Problem lists and diagnoses are maintained appropriately Medication lists are maintained and reconciled Test results and referrals have defined follow-up (closed loop) processes Coding & Billing Coding reflects services and conditions documented Billing processes are reviewed for accuracy Staff receive appropriate coding/billing education Processes exist to identify and correct billing errors Quality & Patient Safety Patient safety events are reported and reviewed Quality measures are monitored Care gaps are identified and addressed Quality improvement activities are documented

In Place

Needs Attention

N/A

☐ ☐

☐

☐ ☐

☐

Notes/Action Needed

128

Compliance Requirement Referral & Care Coordination Referral processes are defined Referral completion is tracked Care transitions have defined processes Medication Management Medication reconciliation process is defined High-risk medication concerns are addressed Medication errors are identified and addressed

In Place

Needs Attention

N/A

☐ ☐ ☐

☐

Notes/Action Needed

Overall Compliance Readiness Current Status: ☐ Ready — Foundational requirements are in place. ☐ Ready with Minor Gaps — Issues identiﬁed but unlikely to prevent implementation. ☐ Needs Improvement — Signiﬁcant gaps should be addressed before implementation. ☐ Not Ready — Critical compliance requirements remain unresolved.

Top Compliance Gaps 1. 2. 3.

Corrective Actions Gap

Corrective Action

Owner

Due Date

Status

✱IF YOU REMEMBER NOTHING ELSE…

Compliance should be proactively built into any workﬂow and not treated as a separate task after the work is done. In VBC, documentation, coding, quality reporting, patient engagement, data sharing, and ﬁnancial incentives are increasingly interconnected. A strong compliance foundation protects the practice while supporting accurate performance measurement and appropriate reimbursement.

WORD TO THE WISE Make the right process the easy process—and build compliance into it from the start.

This appendix is referenced in Part IV: Building Foundational Capabilities

129

Appendix 21: Organizational Destination Planning Worksheet Purpose Use this worksheet to deﬁne what your organization wants to accomplish through Value-Based Care before evaluating payment opportunities or building an implementation roadmap. Establish your strategic priorities, target population, desired outcomes, and tolerance for performance risk, then connect your destination to what you already know about organizational readiness. The destination is the outcome you want to achieve—not a payment model.

1. Deﬁne Our Destination Identify the organizational priorities Value-Based Care should help advance. Focus on the outcomes and challenges that matter most to your organization and community. Select your organization's primary priorities: Strategic Priorities ☐ Improve access to care ☐ Improve patient experience ☐ Reduce total cost of care ☐ Strengthen care coordination ☐ Build population health capabilities ☐ Strengthen ﬁnancial sustainability ☐ Expand services or market presence

☐ Improve quality and patient outcomes ☐ Reduce avoidable utilization ☐ Improve chronic disease management ☐ Improve provider / staff experience ☐ Address an identiﬁed community health need ☐ Improve provider engagement ☐ Other:

Our Primary VBC Goal We want to use Value-Based Care to

What ﬁnancial or organizational sustainability challenge should our VBC strategy help address?

2. Define Our Target Population Which population(s) will we focus on? Identify the patients or populations most likely to benefit from the change you are trying to create. Start with clinical and community need; identify payer alignment when relevant. Population Priorities ☐ Patient with chronic conditions ☐ High-risk /high-need patients ☐Patients with frequent ED or hospital utilization ☐ Patients experiencing access barriers ☐ Patients with significant care-coordination needs ☐ Older adults ☐ Maternal / child population ☐ Other identified population: Population Information What We Know Payer(s), if relevant Estimated population size Primary clinical needs Key barriers / challenges Why is this population a priority?

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3. Deﬁne What Success Looks Like Translate the destination into a small number of outcomes leadership can use to determine whether the strategy is working. Establish a baseline when available and deﬁne the desired future state. Priority Outcome

Where Are We Now?

Where Do We Want to Be?

How Will We Measure It?

Our Deﬁnition of Success We will consider our VBC strategy successful when:

4. Deﬁne Our Performance Risk Tolerance Consider how much performance accountability the organization is prepared to assume as it pursues its VBC goals. Leadership's current position should be tested against organizational readiness before any payment opportunity is pursued. ☐ Prefer limited performance exposure ☐ Comfortable with performance-based incentives ☐ Willing to consider defined downside risk ☐ Prepared to consider greater population-level accountability ☐ Additional evaluation is needed before determining risk tolerance What would make us unwilling to assume greater accountability at this time?

5. Our Organizational Destination Bring Forward What You Already Know (Refer to your completed readiness assessment.) What existing strengths provide the best foundation for the destination you have defined?

Which readiness findings could materially affect your ability to pursue this destination?

Destination Statement Based on the discussion above, describe the future state the organization is working toward. Complete the Destination Statement We are pursuing Value-Based Care to… For… So that…

Response

131

What Will Our Destination Require? Identify the capability domains likely to matter most. The next steps in the playbook will determine which capabilities require strengthening and when. Capability Domains ☐ Leadership & Governance ☐ Operational ☐ Financial

☐ Clinical ☐ Data & Technology ☐ Quality & Compliance

Could strategic partnerships or shared services help provide or strengthen any of the capabilities needed to pursue this destination? ☐ Yes ☐ No ☐ Requires further evaluation If yes, which capabilities?

Leadership Alignment ☐ We agree on the primary organizational goal. ☐ We agree on the population we want to impact. ☐ We agree on what success should look like.

☐ We agree on our current tolerance for performance risk. ☐ We are prepared to use this destination to guide subsequent VBC decisions.

What Still needs to Be Resolved? Before moving from destination-setting to implementation planning, identify questions or areas requiring further evaluation. 1. 2. 3

What Happens Next? Use your Organizational Destination with the readiness ﬁndings from Part II to determine what your organization can reliably execute today and what must be strengthened before implementation.

6. Consider Our Payment Model Destination Once your organizational destination is clear, consider which Outcome-Aligned Payment approaches may support it. The purpose is to identify a potential direction - not committing to a speciﬁc contract or payment model. Organizational readiness, capabilities, ﬁnancial implications, and contract terms must still be evaluated before moving forward. Payment Approach

General Level of Accountability

Potential Direction

Fee-for-Service Plus

Low

☐ Consider

Shared Savings Blended Payment

Low – Mod Moderate

☐ Consider

Episode-Based Payment

Moderate

☐ Consider ☐ Consider

Case-Based Payment

Moderate

☐ Consider

Population-Based Payment Advanced Risk / Capitation

Mod – High High

☐ Consider ☐ Consider

Potential payment direction(s):

How could this payment approach support our organizational destination?

132

✱IF YOU REMEMBER NOTHING ELSE…

Don't let the payment model become the destination. Start with what your organization is trying to accomplish, who you want to impact, and how you will deﬁne success. Then use your readiness, capabilities, and risk tolerance to evaluate which opportunities can help you get there.

WORD TO THE WISE Your destination should drive your Value-Based Care strategy. Never let a payment opportunity deﬁne where your organization is going.

This appendix is referenced in Part V: Pilot, Learn, Improve, and Progress: Implement Conﬁdently. Step 1 – Start with Your Destination Notes

133

Appendix 22: Leadership Alignment Discussion Guide Purpose: Use this guide to determine whether organizational leaders are aligned on the direction, expectations, accountability, and leadership commitments required to pursue Value-Based Care successfully. Surface disagreement and unresolved questions before asking the organization to execute. Alignment does not require every leader to have the same perspective. It requires agreement on the direction, the decisions being made, and who is accountable for what comes next.

1. Leadership Alignment Snapshot Identify where the organization is in its VBC journey and the decision or direction that requires leadership alignment. Current Stage

Select

Exploring VBC

☐

Evaluating an opportunity

☐

Preparing for implementation

☐

Currently operating under VBC

☐

Expanding or progressing our VBC strategy

☐

What decision or direction requires leadership alignment today?

2. Strategic Alignment Conﬁrm that leaders share a common understanding of why the organization is pursuing Value-Based Care and the direction it intends to take. • Why are we pursuing Value-Based Care? • What do we expect VBC to accomplish for our organization, patients, and community? • How does the strategy support our broader organizational priorities? • Are we aligned on the population(s) we intend to impact? • What would cause us to reconsider our direction? Are we aligned on our VBC direction?

☐ Aligned

☐ Issues to Resolve

☐ Not Yet Aligned

Areas requiring further discussion:

3. Alignment on Success Refer to the Organizational Destination Planning Worksheet. Conﬁrm that leadership agrees on the outcomes that will deﬁne success and how performance will be recognized. • Are we aligned on the outcomes that matter most? • Are we aligned on how success will be measured? • Are we aligned on the timeframe in which meaningful progress should be expected? Leadership position: ☐ Aligned

☐ Issues to Resolve

☐ Not Yet Aligned

Unresolved issues:

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4. Financial & Performance Risk Alignment Confirm that leadership shares a common understanding of the financial implications and level of performance accountability the organization is prepared to consider. • Are we aligned on our tolerance for performance and financial risk? • Are we aligned on the level of investment we are prepared to consider? • Do we agree on the financial boundaries or conditions that would require further evaluation before proceeding? • Are leaders clear about which financial questions still require modeling or expert review? Leadership position: ☐ Aligned

☐ Issues to Resolve

☐ Not Yet Aligned

Financial or risk issues requiring further evaluation:

5. Clinical Alignment Conﬁrm that leadership agrees on the clinical direction required to support the VBC strategy. • Are we aligned on the patient population and clinical outcomes that matter most? • Are we aligned on the care-delivery changes likely to be required? • Are we prepared to address unwarranted clinical variation when it affects outcomes or performance? • Are clinical leaders appropriately involved in VBC decisions? • Are we aligned on where clinical accountability will reside? Leadership position: ☐ Aligned

☐ Issues to Resolve

☐ Not Yet Aligned

Clinical issues requiring further discussion:

6. Provider & Team Engagement Determine whether leadership is aligned on how providers and frontline teams will be engaged, supported, and held accountable. • Do we agree on how the VBC strategy will be communicated? • Are we prepared to explain how workﬂows and expectations may change? • How will providers and teams receive meaningful performance feedback? • Are expectations and accountability clear? • How will provider and staff experience be monitored? • Who will serve as clinical and operational champions? • What resistance or implementation barriers should leadership anticipate? Are we aligned on the engagement approach? ☐ Aligned

☐ Issues to Resolve

☐ Not Yet Aligned

Concerns requiring action:

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7. Leadership Accountability & Decision Rights Translate leadership alignment into clear ownership and decision authority before implementation begins. Leadership Accountability

Owner

Executive sponsorship Clinical leadership Operational implementation Financial oversight Quality / performance oversight Data / performance reporting

Who has authority to make implementation decisions?

Which decisions require executive or governing-body approval?

How will unresolved issues be escalated?

8. Non-Negotiables & Leadership Alignment Decision What must be true before we move forward?

Leadership Alignment Decision ☐ Aligned — Move Forward with the Agreed Direction

☐ Further Leadership Discussion Required

☐ Aligned with Conditions — Resolve Identiﬁed Issues

☐ Reconsider Current Direction

☐ Additional Readiness Work Required Conditions / Unresolved Issues

Owner

Resolution Date

✱IF YOU REMEMBER NOTHING ELSE…

VBC alignment is achieved when everyone understands what saying “yes” means. Leaders must agree on the direction, deﬁnition of success, acceptable risk, expectations of providers and teams, and who is accountable for what comes next. Unresolved disagreement at the leadership level eventually becomes confusion at the operational level.

WORD TO THE WISE Align at the top before asking the organization to execute below.

This appendix is referenced in Part V: Pilot, Learn, Improve, and Progress: Implement Conﬁdently, Step 1 — Start with Your Destination. © 2026 Synergy 3C – The Clinical Consulting Cooperative, LLC. All Rights Reserved.

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Appendix 23: Capability Prioritization Matrix Purpose Prioritize the capabilities that are most critical to the success of the initial VBC implementation, determine whether they must be reliable before launch, and identify how each capability will be delivered. Capability

Critical to MVP? ☐ Yes ☐ No

Ready for Launch? ☐ Yes ☐ No

Delivery Approach

☐ Build ☐ Partner ☐ Shared Service ☐ Workaround

☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No

☐ Build ☐ Partner ☐ Shared Service ☐ Workaround ☐ Build ☐ Partner ☐ Shared Service ☐ Workaround ☐ Build ☐ Partner ☐ Shared Service ☐ Workaround ☐ Build ☐ Partner ☐ Shared Service ☐ Workaround

Prioritization Decision List the critical capabilities that must function reliably before MVP launch: 1. 2. 3. 4. What are the capabilities that can be strengthened during implementation? 1. 2. 3. 4. What are the temporary workarounds requiring a replacement plan? 1. 2. 3. 4.

WORD TO THE WISE Prioritization is about impact. Focus ﬁrst on the relatively small number of capabilities that will drive the majority of your MVP's success. A capability does not have to be perfect or fully built internally—but it must function reliably enough to support the level of accountability you are taking on.

This appendix is referenced in Part V: Pilot, Learn, Improve, and Progress

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Appendix 24: Strategic Partnership Planning Worksheet Purpose Use this worksheet after selecting a strategic partner or shared service to deﬁne roles, responsibilities, implementation requirements, communication, performance expectations, and accountability. The goal is to ensure the partnership is operationally ready and aligned with the organization's VBC strategy before implementation begins.

1. Partnership Overview Partner/Organization: Market or Practice: Capability/Problem Being Addressed: Expected Outcome: Implementation Start Date: Go-Live Date Internal Executive Sponsor: Internal Operational Owner: Partner Lead / Contact

2. Roles & Responsibilities Activity / Responsibility Implementation Workflow development Staff training Patient engagement Data / reporting Clinical escalation Quality monitoring Issue resolution Other responsibilities:

Our Organization ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

Partner

Shared

☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

☐

Notes

3. Implementation Readiness Requirement Workﬂow deﬁned

Ready? ☐ Yes ☐ No

Staff identiﬁed Training completed

☐ Yes ☐ No

Technology integrated

☐ Yes ☐ No ☐ Yes ☐ No

Data access established

☐ Yes ☐ No

Reporting established Compliance requirements addressed

☐ Yes ☐ No ☐ Yes ☐ No

Clinical escalation process established

☐ Yes ☐ No

Patient communication prepared

☐ Yes ☐ No

Action Needed

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Requirement Clinical escalation process established Patient communication prepared

Ready? ☐ Yes ☐ No

Action Needed

☐ Yes ☐ No

4. Performance & Accountability What are our primary measures of success? (how will we know we are successful?) 1. 2. 3.

How often will performance be reviewed? ☐ Weekly ☐ Monthly ☐ Quarterly ☐ Other: __________________ Who will review performance? What happens if performance expectations are not met?

6. Communication & Escalations Deﬁne how routine communication and issues requiring escalation will move between the organizations. Identify the appropriate contact on each side and establish the expected communication or escalation process. Communication Organization Partner Method/Process /Escalation Area Lead Lead/Contact Process: Routine Communication Frequency: Urgent / Patient Safety Escalation Clinical Escalation Operational Escalation Executive Escalation

7. Partnership Review Periodically evaluate whether the partnership is delivering the intended value and identify changes needed to strengthen performance. Review Area Findings / Actions What is working well? What is not working as expected? What needs to change?

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Should the partnership continue? ☐ Yes ☐ Continue with modiﬁcations ☐ Further evaluation needed ☐ Discontinue

✱IF YOU REMEMBER NOTHING ELSE…

Successful partnerships require more than selecting the right partner. They require clearly deﬁning who owns what, how the organizations will work together, how performance will be measured, and how problems will be addressed before implementation begins.

WORD TO THE WISE Don't confuse a signed partner contract with an operationally ready partnership. The work begins after the agreement is signed. Establish clear ownership, communication, escalation, and performance expectations from the start—and revisit them regularly as the partnership evolves.

This appendix is referenced in Part V: Pilot, Learn, Improve, and Progress Notes

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Appendix 25: MVP Scope Planning Template Purpose Any initiative will fail without buy-in, planning, accountability, and communication. This template allows organizations to establish a scope for each pilot to prevent “creep” into other areas not related to the speciﬁc project or improvement activity they are piloting.

Creating an MVP Project Charter Creating a project charter gives a structure to the project and deﬁnes the scope and goals of the initiative. •

The scope should only include the interventions in the dashboard. Reduce risk of “scope-creep” by determining what is out of scope for this project but could be considered for later pilots.

•

Assign roles and state high-level responsibilities speciﬁc to the pilot.

Project Title: Project Manager: Project Champion:

Purpose Background What is the project intended to accomplish (SMART What is the context for this project? goals)?

Scope Success Criteria What is in scope for this project? This could include How will you know if the project is successful? patient inclusion criteria. How will you monitor performance?

What is out of scope?

Roles Responsibilities What are the roles needed for this project? This What activities is each role responsible for could include patient exclusion criteria. performing?

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✱IF YOU REMEMBER NOTHING ELSE…

A pilot is designed to learn without having to solve everything at once. The greatest threat to a successful pilot is often not a lack of ideas, but too many ideas competing for limited time, resources, and attention. A clear project charter creates the boundaries that allow the team to stay focused on the few interventions most likely to produce meaningful results. Deﬁne the why, what, who, when, and how before the work begins. Make the SMART goals measurable, assign clear ownership, establish what is in and out of scope. When new ideas emerge—and they will— capture them for future consideration rather than allowing them to derail the current pilot.

WORD TO THE WISE Start small, stay focused, learn quickly, and scale what works. A disciplined pilot creates evidence for the next decision or next pilot.

This appendix is referenced in Part V: Pilot, Learn, Improve, and Progress Notes

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Appendix 26: Vision and Direction Communication Planner Purpose Use this planner to communicate the vision, direction, and rationale for organizational change in a way that builds understanding, alignment, and engagement. Identify who will be affected, anticipate questions and concerns, deﬁne the messages that matter most, and create a communication approach that gives teams a meaningful role in implementation. Communication should begin before implementation and continue as the work evolves. Use feedback, performance results, milestones, and lessons learned to reinforce the vision and address concerns as they emerge.

1. Know the Audience and the Change Before communicating the change, identify who will be affected, what they need to know, and where questions or resistance are likely to emerge. Planning Question What is changing? Why is the change needed? Who will be most affected? What concerns or pain points should we anticipate? What will be different for patients? What will be different for providers and staff?

What We Know

Communication Channels ☐ Huddles

☐ Staff meetings

☐ Leadership meetings

☐ Email ☐ Training ☐ Other: __________________

2. Communicate the Why Explain why the change matters before explaining what people will be asked to do. Connect the vision to the problem being addressed and the future state the organization is working toward. Message to Communicate

Our Message

Why are we making the change? What problem are we trying to solve? How will patients beneﬁt? How will provider and staff beneﬁt? How does the change support our organizational direction?

3. Engage the Team in the How Leadership sets the direction. Engage the people closest to the work in designing how the change will be implemented. Implementation Engagement

Who needs to help design the workﬂow? Which roles will be affected? What decisions should frontline teams help make? Who will serve as champions? How will questions and concerns be surfaced? How will we check for engagement, burden, or implementation barriers?

Plan

Everyone affected by the change should understand their role and what is expected of them.

143

4. Make Progress Visible Keep the vision visible as implementation progresses. Communicate results, milestones, lessons learned, and changes made along the way so teams can see how their work is moving the organization toward the intended future state. What We Will Communicate Performance results Milestones / early wins Patient stories / experience Provider and staff feedback Lessons learned / changes made

How / Where

Frequency

Owner

Communication Pulse Check How will we know our communication approach is working?

Celebrate the “What” Make success visible, too. Celebrate progress and recognize the people making it possible. Share patient success stories, acknowledge team contributions, and communicate meaningful wins as they occur. What are the wins worth celebrating?

People/teams to recognize: 1. 2. 3.

4. 5. 6.

✱IF YOU REMEMBER NOTHING ELSE…

People resist change when they do not understand it, trust it, or see how they ﬁt into it. Explain why the change matters. Involve the people closest to the work in determining how it will be implemented, and communicate consistently as the work progresses. Communication is not complete until the message is understood as intended. Pay attention to what people heard, what they need, and what the organization is experiencing as the change takes hold.

From Simon Sinek’s Start with Why

WORD TO THE WISE You cannot communicate people into commitment. You build commitment by giving people a reason to believe, a voice in the process, and evidence that the change is making a difference.

This appendix is referenced in Part V: Pilot, Learn, Improve, and Progress

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Appendix 27: Minimum Viable Pilot (MVP) Planning Worksheet Purpose Use this worksheet to design a focused Minimum Viable Pilot (MVP) that tests your care model, workflows, capabilities, and performance assumptions under real-world conditions. Start with a defined population, clear objectives, and manageable scope. Design the patient journey first, then build the clinical and operational model required to deliver it. Patient Journey and Longitudinal Patient Management represent two perspectives of the same care model: •

Patient Journey deﬁnes the care experience from the patient's perspective.

•

Longitudinal Patient Management deﬁnes the clinical and operational model required to deliver that experience consistently.

Successful Value-Based Care intentionally designs both.

1. Conﬁrm MVP Readiness Bring forward the readiness and capability-prioritization work completed earlier in the playbook. Apply the 80/20 Rule to the speciﬁc capabilities required for this pilot. Approximately 80% of the capabilities critical to MVP success should be functioning reliably before launch. Remaining gaps may be addressed through internal development, strategic partners, shared services, or temporary workarounds, provided the solution is reliable and does not create unacceptable burden, inefficiency, or risk. Capability Question

Yes

Have we identiﬁed the capabilities that are critical to this MVP? Are approximately 80% of those critical capabilities functioning reliably today? For capabilities that are not fully developed, do we have a reliable way to provide them? Are temporary workarounds manageable and unlikely to create excessive burden or risk? Are needed partners or shared services in place and ready to perform? Are any unresolved capability gaps signiﬁcant enough to jeopardize pilot performance? Is leadership prepared to proceed with the remaining level of risk?

Needs Attention

☐ ☐ ☐ ☐ ☐ ☐ ☐

Do we have enough of the capabilities critical to this pilot functioning reliably to proceed? ☐ YES

☐ NO

If no, what are the capability gaps that must be addressed before launch?

2. Deﬁne the MVP Create a concise charter that establishes what the pilot will test, who it will serve, and the boundaries within which it will operate. MVP Element Purpose Target population Primary objective(s) Participating providers / locations Payer / partner, if applicable Pilot duration Scope / boundaries Executive sponsor Operational lead

Deﬁne

145

What Are We Testing? State the pilot hypothesis in plain language: If we __________________________________ for __________________________________, we expect_______________________ ____________________________________________ because _________________________________________________________.

3. Design the Patient Journey Map the experience you want patients to have from identiﬁcation through ongoing management. Use the Patient Journey Mapping Tool to identify touchpoints, handoffs, barriers, and places where patients could experience delays or gaps in care. Patient Journey Question

MVP Design Response

Where are the most critical patient touchpoints? Where will patients need additional support? Where are delays, failed handoffs, or disengagement most likely? What must the MVP do differently to address them? Related Tool: Patient Journey Mapping Tool

4. Design Longitudinal Patient Management Deﬁne the clinical and operational model required to deliver the intended patient journey consistently. Program Delivery Phase

MVP Design Decisions

Identiﬁcation

Who is included? How will eligible patients be identiﬁed?

Stratiﬁcation

How will risk be assessed, and how will risk determine care intensity?

Outreach

Who will engage patients and providers, and how?

Enrollment

How will patients enter the program, and what expectations will be established?

Engagement

How will care and communication be sustained between visits? How will changes in risk trigger action?

Evaluation & Reporting

How will performance be monitored, reported, and used to improve the model?

5. Build the Workflows Required to Deliver the MVP Translate the patient journey and longitudinal care model into the workflows required to deliver the MVP reliably. Map only the workflows necessary to execute the pilot. Workflow Needed

Owner

Ready?

Tool / Process Needed

☐ ☐ ☐ ☐ ☐ ☐ ☐

Assign ownership for every workﬂow and handoff. Related Tools: Appendix 9 – Roles, Responsibilities and Accountability Template

146

6. Prepare for Launch Confirm that the people, processes, technology, measures, and oversight required for the MVP are ready before implementation begins. Launch Readiness Leadership approval Roles and accountability defined Staff education completed Critical workflows tested Technology and data requirements ready Performance reporting established Pilot measures and baseline finalized Known risks have mitigation plans Governance / escalation process established

Conﬁrmed ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

7. Deﬁne How the MVP Will Be Evaluated Deﬁne how you will know whether the MVP performed as intended before the pilot begins. Establish a focused set of measures and a regular review cadence. Performance Dimension

Measures

Baseline

Target

Review Frequency

Clinical Operational Financial Patient experience Provider / staff experience Evaluation Planning

Deﬁne

Who will review performance? How often will performance be reviewed? How will lessons and unexpected ﬁndings be captured?

8. After the Pilot Use the Pilot Evaluation & Lessons Learned Template to determine what worked, what needs improvement, and what the organization learned. Use SWOT or Root Cause Analysis when deeper analysis is warranted. Apply the ﬁndings to strengthen the model and determine the appropriate next step. Related Tools: Pilot Evaluation & Lessons Learned Template; Pilot SWOT Analysis Template; Root Cause Analysis Template; Improvement Action Plan; Are We Ready to Advance? Decision Tool

✱IF YOU REMEMBER NOTHING ELSE…

Keep the pilot focused enough to learn what works and what does not. Deﬁne what you are testing, measure the results, and use what you learn to determine what comes next.

WORD TO THE WISE Start focused. Learn deliberately. Strengthen before you scale.

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This appendix is referenced in Part V: Pilot, Learn, Improve, and Progress, Step 4 — Design Your Minimum Viable Pilot (MVP). Notes

148

Appendix 28: MVP Action Plan Purpose Each project should start with a kick-off that includes anyone involved in or impacted by the changes being implemented. This allows you to get input on the tasks involved in initiating the new process(es). Make sure you complete Appendix 26: Vision and Direction Communication Planner ﬁrst! A kick-off gives you the opportunity to explain the “why” behind the changes and get buy-in. It’s important to document each task in the process to ensure crucial steps aren’t missed. You should consider all teams involved: leadership, clinical, ﬁnance, data, IT, billing, coding, scheduling, etc. It’s also a good idea to group the project into phases.

Project Template •

•

Planning o Determine the resources (internal, external, shared or vendor) needed. o Identify technology changes needed. o Identify all who might be impacted by the change. o Assign a person responsible for each planning task and assign start and end dates. Executing o Identify each step needed to implement the interventions. o Get input from all internal and external stakeholders who could be impacted by the changes. o Assign a person responsible for each task and set start and end dates. o Establish a cadence for meeting to track progress toward end dates. o Establish a cadence for reporting progress towards completion of the project. Reviewing o Review and edit tasks as the project goes along to capture any steps or tasks identiﬁed during the project. o Keep a running list of “lessons learned” during the project. o Identify any risks to the project and strategies used to mitigate the risks. Communicating o Communicate high level progress to leadership using a standard template (below) at the established cadence. o Escalate any risks or unintended consequences to leadership as they arise. o Create internal and external communications announcing the interventions identiﬁed to meet the goals. o Author policies, procedures, and job aids to align with the interventions once they are completed.

149

o Status

Task

Responsible

Start Date

Projected End Date

Actual End Date

Start Date

Projected End Date

Actual End Date

Phase 1: Planning

Phase 2: Executing

Phase 3: Reviewing

Phase 4: Communicating

Communication Template for Leadership Status

Milestones (Phases) Planning Executing Reviewing Communicating

Statuses: NS – Not started

S – Started

Responsible

I – In progress

% Complete

C – Complete

T - Terminated

✱IF YOU REMEMBER NOTHING ELSE…

A plan is only as strong as the accountability behind it. Deﬁne the work, assign one accountable owner, set realistic timelines, and review progress consistently. Address barriers early, adjust the plan as you learn, and keep the team connected to why the work matters.

WORD TO THE WISE If everyone is responsible, no one is responsible. Assign ownership, track progress, address barriers, and communicate often. Execution is where improvement becomes reality.

This appendix is referenced in Part V: Pilot, Learn, Improve, and Progress Notes

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Appendix 29: MVP Evaluation & Lessons Learned Purpose Use this tool after completing a Value-Based Care MVP to determine what worked, what did not, why the results occurred, what should change, and what the organization should do next. The tool can be used regardless of payer, payment model, or for an MVP with any collaborative structure affiliation.

WORD TO THE WISE: The goal of an MVP is to learn before expanding. A successful first cycle is encouraging, but repeatable performance matters more than a single good result.

7. Pilot Snapshot Field

Organization / Practice MVP Name MVP Lead / Owner Pilot Period Patient Population Payer / VBC Arrangement Why This Pilot? What Are We Testing? What Does Success Look Like?

What to Enter

Name of the organization or practice conducting the pilot Brief name for the pilot Business owner for the pilot Start and end dates Specific group of patients included in the pilot Payer and payment arrangement, if applicable The specific problem or opportunity the organization chose to address The change in care delivery, workflow, or capability being tested The measurable result(s) the organization expects the pilot to achieve

Pilot Snapshot Notes

8. Compare Expected and Actual Results List the measures you planned to use to judge the pilot. Include only measures that matter to the pilot, such as clinical outcomes, quality, utilization, patient experience, workﬂow performance, or ﬁnancial results.

Measure 1: Starting Point

Expected Result

Actual Result

What was different from what we expected?

Measure 2: Starting Point

Expected Result

Actual Result

What was different from what we expected?

151

Measure 3: Starting Point

Expected Result

Actual Result

What was different from what we expected?

Measure 4: Starting Point

Expected Result

Actual Result

What was different from what we expected?

Additional measures may be added as needed. <measure section may be copied and pasted>

9. Did We Give the Pilot a Fair Test? Before judging the model, confirm that the pilot was carried out well enough to evaluate it fairly. Check We identified the intended patient population correctly. Enough eligible patients enrolled or engaged to reasonably evaluate the pilot? Enough patients remained in the pilot long enough to reasonably evaluate the care model. The planned care changes were actually carried out. Important handoffs and referrals were completed reliably. Patient needs between visits were addressed as intended. Staff knew who owned each part of the work. Staff had enough time, skills, and support to do the work. Staff had the information needed to identify, manage, and follow patients. Technology supported the work without creating major barriers. We could measure the pilot results with reasonable confidence.

Yes

Partly

Notes / Evidence

WORD TO THE WISE Do not label the care model unsuccessful until you know the planned model was actually delivered.

152

10. What Inﬂuenced the Results? Review each area below and identify what meaningfully helped or hindered pilot performance. Focus on factors that affected the results. Area

Question to Ask

Patient Population

Was the selected population appropriate and manageable for a ﬁrst VBC pilot?

Care Approach(es)

Was the care approach appropriate for the needs and risks of the selected population?

Patient Journey & Continuity

Were patients effectively managed across visits, referrals, transition, and the time between encounters?

BetweenVisit Care

Were patient needs addressed between visits, not only during scheduled encounters?

Workﬂow

Did the workﬂow support reliable, repeatable delivery of the care model?

People & Capacity

Were roles, staffing, skills, and accountability sufficient?

Data

Did the team have timely, reliable information to identify needs, make decisions and track performance?

Technology

Did the technology support the work effectively, or did it create barriers or workarounds?

Patient Engagement

Were patients able and willing to participate and follow through with the care plan?

Ongoing Participation

Did patients remain engaged in the program long enough to receive the intended care and support?

Partners & Shared Services

Did externa partners and services reliably perform the functions the pilot depended upon?

Key Findings

Impact on Pilot ☐ Helped ☐ Hindered ☐ Both ☐ Neutral ☐ Helped ☐ Hindered ☐ Both ☐ Neutral ☐ Helped ☐ Hindered ☐ Both ☐ Neutral ☐ Helped ☐ Hindered ☐ Both ☐ Neutral ☐ Helped ☐ Hindered ☐ Both ☐ Neutral ☐ Helped ☐ Hindered ☐ Both ☐ Neutral ☐ Helped ☐ Hindered ☐ Both ☐ Neutral ☐ Helped ☐ Hindered ☐ Both ☐ Neutral ☐ Helped ☐ Hindered ☐ Both ☐ Neutral ☐ Helped ☐ Hindered ☐ Both ☐ Neutral ☐ Helped ☐ Hindered ☐ Both ☐ Neutral

153

Area

Question to Ask

Financial & Resource Assumptions

Were the staffing, time, cost, revenue, and payment assumptions underlying the pilot reasonably accurate?

External Factors

Did circumstances outside the organization’s control materially affect performance?

Key Findings

Impact on Pilot ☐ Helped ☐ Hindered ☐ Both ☐ Neutral ☐ Helped ☐ Hindered ☐ Both ☐ Neutral

WORD TO THE WISE

Look for what helped the pilot succeed as carefully as you look for what got in the way. Both should shape the next cycle.

Need to dig deeper? Use the MVP SWOT to take a broader look at what helped or challenged the pilot. Use the Fishbone analysis when a speciﬁc program needs deeper causal analysis.

11. Look More Closely at What Mattered Select the most important ﬁndings from Section 4 and determine their drivers. Complete one analysis for each ﬁnding that materially affected the pilot. What worked well?

Why did it work?

What did not work as intended?

Why didn’t it work?

What was the underlying cause?

What evidence supports this conclusion?

154

The main factor(s) appear(s) to be ☐ Care approach/clinical model components ☐ Ongoing program participation ☐ Workﬂows ☐ Partner/Shared Service ☐ People/capacity ☐ Financial/resource assumption ☐ Data/Data usability ☐ External factor ☐ Other: ☐ Technology ___________________________________________ ☐ Patient engagement Can we course-correct? ☐ Yes, with minor change(s) ☐ Yes, but additional capability is needed

☐ Unsure. Test again ☐ No, signiﬁcant redesign is needed ☐ Financial/resource assumption

WORD TO THE WISE Do not stop at what went wrong. Keep asking “why” until you identify something the organization CAN address.

Keep | Fix | Build | Watch Use what you learned from the pilot to determine what should continue, change, or receive closer attention in the next cycle.

KEEP What worked and should continue?

FIX What needs to work better next time?

BUILD What capability is missing or needs strengthening?

WATCH What risk or external factor needs closer attention?

WORD TO THE WISE

Keep this list focused. Prioritize what will have the greatest impact on the next pilot cycle.

12. Action Plan for the Next Cycle What Needs Attention?

Actions to Take

Owner

How will We Know It Worked?

Required Before Next Cycle? ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No

155

Logical Next Step: Based on what we learned from the pilot, we will ☐ Repeat the pilot ☐ Repeat with changes ☐ Address capability gaps begore repeating ☐ Redesign the pilot before proceeding ☐ Move forward with the next appropriate VBC step

Are We Ready for the Next Step? Use this ﬁnal check before expanding the pilot, making the model part of routine operations, or pursuing the next Value-Based Care opportunity. Before Moving Forward, Can We Say…

Yes

We can repeat the care model reliably.

☐

Not Yet ☐

The most important gaps identiﬁed during the pilot have been addressed or have a clear plan.

☐

Patients can move through the care journey without known critical gaps.

☐

We can engage patients and keep them participating long enough for the model to work.

☐

We can manage patient needs between visits as intended.

☐

We have the people, workﬂows, data, technology, and partnerships needed to sustain the model.

☐

We can measure performance reliably.

☐

We understand the resources and ﬁnancial implications well enough to make the next decision.

☐

Our Next Step Based on what we have learned from this MVP, our next step is

What must be true before we take that step?

This appendix is referenced in Part V: Pilot, Learn, Improve, and Progress Notes

156

Appendix 30: MVP SWOT Template Purpose This template is designed to provide a structured assessment of the pilot’s performance and the organization’s readiness to evolve, expand, or sustain the model. By examining internal strengths and weaknesses alongside external opportunities and threats, the SWOT helps the team identify what worked, what did not, and what should be addressed before moving forward. Use this in conjunction with Appendix 31: Root Cause Analysis Worksheet

S= STRENGTHS What internal capabilities helped the pilot to be successful? • • • Comments:

W=WEAKNESSES What internal gaps or limitations hindered performance? • • • Comments:

O= OPPORTUNITIES What could strengthen or expand the model? • • • Comments:

T=THREATS What external factors could threaten success or sustainability • • • Comments:

157

✱IF YOU REMEMBER NOTHING ELSE…

A successful MVP is not the ﬁnish line. It is only the beginning of a roadmap. Look beyond what worked. Use the SWOT to identify gaps, unexpected challenges, and external factors that could affect what comes next. Be candid about what did not work, then decide what to scale, strengthen, stop, or rethink.

WORD TO THE WISE

Learn from the pilot before you scale the model.

This appendix is referenced in Part V: Pilot, Learn, Improve, and Progress Notes

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Appendix 31: Root Cause Analysis Worksheet Purpose Use this worksheet to identify why a problem, performance gap, or unexpected outcome occurred and determine what must change to prevent recurrence. Root Cause Analysis (RCA) should address the conditions that allowed the problem to occur rather than assign blame.

13. Deﬁne the Problem and Its Impact Problem Deﬁnition What happened? What was expected? Where and when did it occur? Who or what was affected? How often has it occurred?

Response

Impact: ☐ Patient/Member Experience ☐ Clinical Quality ☐ Provider/Staff Experience ☐ Operations ☐ Financial ☐ Compliance/Risk ☐ Data/Reporting ☐ Technology ☐ Other: __________ Problem Statement: ________________________________________________________________________________________

14. Determine Why It Happened — 5 Whys Start with the problem and continue asking why until you reach a cause that explains why the problem occurred and can meaningfully inform corrective action. Ask why until there is not viable answer. Five is a guide, not a requirement. Question Finding Problem: Describe what happened Why? Why? Why? Why? Why? Root Cause Identiﬁed:

15. Identify Contributing Factors Look beyond the ﬁrst explanation. Identify conditions that contributed to the problem or allowed it to occur. Factor Contributed? Key Finding People / Staffing ☐ Process / Workﬂow ☐ Leadership / Governance ☐ Training / Knowledge ☐ Data / Analytics ☐ Technology / Systems ☐ Communication ☐ Resources / Capacity ☐ Policy / Procedure ☐ Patient / Member ☐ Payer / External ☐

159

Primary Root Cause:

Within our control? ☐ Yes ☐ Partially ☐ No

16. Deﬁne Corrective and Preventive Action Address the root cause and the conditions that contributed to it. Action Needed

Corrective / Preventive ☐C ☐C ☐C

Owner

Due Date

Status

☐P ☐P ☐P

19. Deﬁne How Improvement Will Be Measured Select the measures that will show whether the root cause has been addressed and the desired improvement is sustained. Measures

Baseline

Target

Data Source

Review Frequency

Owner

20. Validate the Fix Close the loop by conﬁrming implementation, monitoring recurrence, and determining whether additional action is needed. Validation Question Corrective action implemented? Problem recurred? Desired outcome achieved? Additional action required?

Status ☐ Yes ☐ No ☐ In Progress ☐ Yes ☐ No ☐ Unknown ☐ Yes ☐ No ☐ Partially ☐ Yes ☐ No

If additional action is required:

✱IF YOU REMEMBER NOTHING ELSE…

Do not stop at what went wrong. Determine why it happened and what must change to keep it from happening again. Look beyond the ﬁrst explanation. The root cause may sit in the workﬂow, technology, data, staffing, leadership, or another condition that allowed the problem to occur.

WORD TO THE WISE: Fix the system—not just the symptom.

This appendix is referenced in Part V: Pilot, Learn, Improve, and Progress Notes

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Appendix 32: Value-Based Care Roadmap Purpose Use this tool to build a practical, phased Value-Based Care roadmap based on your organization's priorities, capabilities, resources, and evidence from implementation. The roadmap should identify what to build or strengthen next, what to defer, how needed capabilities will be obtained, and what evidence is required before progressing. It is not a ﬁxed timeline. Revisit it as performance, capabilities, priorities, and opportunities change. Progress should be earned through capability, performance, and evidence.

This graphic directly reﬂects the principle that there is no universal VBC roadmap; the organization's priorities, capabilities, resources, and goals should determine its path.

Roadmap at a Glance 1. Deﬁne

2. Assess

3. Prioritize

4. Pilot

Deﬁne the destination

Know where you stand

Decide what matters most

Test before scaling

5. Measure & Learn Evaluate, learn & improve

6. Progress Decide what comes next

1. Deﬁne Your Destination Objective: Establish where the organization wants to go before deciding what to build, pursue, or contract for. Bring forward: Organizational Destination Planning Worksheet; Leadership Alignment Discussion Guide Roadmap Question What are we trying to accomplish through VBC? Which population(s) are we trying to impact? What outcomes will deﬁne success? What level of performance risk are we prepared to assume?

What We Know

Ready to move forward? ☐ Goals & outcomes deﬁned ☐ Target population identiﬁed ☐ Risk tolerance discussed ☐ Leadership aligned

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2. Know Where You Stand Objective: Assess current organizational capabilities and identify the strengths, gaps, and barriers that will influence the VBC strategy. Bring forward your readiness findings and identify the capabilities, gaps, and barriers that will influence the roadmap. Use this tool: Capability Inventory Worksheet; Value-Based Care Readiness Assessment Readiness Finding What We Know Capabilities we can rely on today Critical capability gaps Barriers that could affect performance Capabilities most relevant to our next phase Ready to move forward? ☐ Current capabilities known ☐ Critical gaps identified ☐ Readiness implications understood

3. Prioritize What Matters Most Objective: Translate the readiness assessment into a small number of actionable priorities. Apply the 80/20 Rule and focus first on the capabilities most likely to affect the success of your next phase rather than trying to fix everything at once. Capability Gap

Impact

Risk if Unaddressed

Feasibility

☐High ☐ Med ☐ Low ☐High ☐ Med ☐ Low ☐High ☐ Med ☐ Low ☐High ☐ Med ☐ Low ☐High ☐ Med ☐ Low

MVP / NextPhase Relevance ☐High ☐ Med ☐ Low ☐High ☐ Med ☐ Low ☐High ☐ Med ☐ Low ☐High ☐ Med ☐ Low ☐High ☐ Med ☐ Low

Priority

☐High ☐ Med ☐ Low ☐High ☐ Med ☐ Low ☐High ☐ Med ☐ Low ☐High ☐ Med ☐ Low ☐High ☐ Med ☐ Low

Decide How Critical Capabilities Will Be Provided Select only the highest-priority gaps for the initial phase. A needed capability may be built internally, provided through a strategic partner or shared service, or supported by a manageable temporary workaround. High-Priority Gap

Build Internally

Partner

Shared Service

Temporary Workaround

☐

The goal is organizational capability rather than complete organizational self-sufficiency. Ready to move forward? ☐ Critical priorities selected ☐ Non-critical gaps intentionally deferred ☐ Capability sourcing decisions made ☐ Resources identiﬁed

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4. Pilot Before You Scale Objective: Use a focused MVP to test signiﬁcant new elements of the roadmap before implementing them broadly or assuming greater risk. Bring forward: Minimum Viable Pilot (MVP) Planning Worksheet; MVP Action Plan; Financial Modeling & ROI Worksheet Pilot Decision Response What roadmap priority is being tested? What do we need to prove or learn? What is the smallest meaningful scope? What evidence will support moving forward? Ready to pilot? ☐ The roadmap priority and what we need to test are clear ☐ Measures and baseline are established ☐ The pilot scope is focused and manageable ☐ Data and reporting can support evaluation ☐ Critical workﬂows and capabilities are ready

☐ Risks and resources requirements are manageable

☐ Roles and accountability are assigned

☐ Leadership has approved the pilot

Note: Not every roadmap priority requires an MVP. Using one when testing on a smaller scale can reduce uncertainty, burden, or risk before broader implementation

5. Measure, Learn & Improve Objective: Use pilot performance and experience to strengthen the model and inform the next roadmap decision. Bring forward: Pilot Evaluation & Lessons Learned; Pilot SWOT Analysis; Root Cause Analysis Worksheet; Core ValueBased Care Metrics Dashboard Pilot Review What We Learned What worked? What needs improvement? What did we learn that changes our assumptions? What needs to change before the next phase? Ready to decide what comes next? ☐ Performance reviewed ☐ Lessons documented ☐ Root causes addressed where needed ☐ Financial performance evaluated ☐ Leadership reviewed ﬁndings

6. Decide What Comes Next Use evidence from the current phase to determine the organization's next appropriate level of scope and accountability. Roadmap Decision STRENGTHEN SCALE EXPAND ASSUME MORE RISK REPEAT THE MVP PAUSE / REASSESS

When It Fits Improve existing capabilities before expanding. Extend a successful model to more providers, locations, or patients. Add conditions, populations, services, or payers. Move toward greater financial or performance accountability. Run another focused pilot when important uncertainty remains. Address significant capability, performance, or financial concerns before proceeding.

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VBC Progression Organizational maturity may progress from exploration and preparation through pilot, consistent performance, expansion, greater accountability, and sustained improvement. Progression is not automatic. Progression Explore Prepare Pilot Perform Scale Advance Sustain

Primary Focus Deﬁne strategy Build foundational capabilities Test capabilities and workﬂows Demonstrate consistent results Expand successful capabilities Assume greater accountability Continuously improve and optimize

Typical Accountability Minimal Minimal–Moderate Moderate Moderate Increasing Higher Mature

Roadmap Decision Gate CONTINUE / PROGRESS Performance supports the next phase

STRENGTHEN Performance is mixed

Critical capabilities are reliable

Critical gaps or workﬂow issues remain Data or engagement limitations remain Additional improvement is needed

Financial performance is acceptable Risks are understood and manageable

STOP / REASSESS Financial or performance risk is unacceptable Critical capabilities cannot be delivered reliably Key assumptions proved incorrect Expected value no longer supports investment

7. Build Your Roadmap Objective: Bring the decisions from Stages 1–6 together into a sequenced plan. Start with the priorities your organization is ready to act on now. Then identify what should follow as capabilities and performance strengthen. Do not advance an item simply because time has passed; deﬁne what must be demonstrated before moving forward. Roadmap Priority

What Will We Do?

How Will We Do it?

Now Next Later

Owner

Target Timing

What Must Be True to Progress?

Continuous VBC Cycle DEFINE → ASSESS → PRIORITIZE → PILOT → MEASURE → LEARN → IMPROVE → PROGRESS Then reassess, reprioritize, and determine what comes next. Every pilot should leave the organization stronger than when it began.

✱IF YOU REMEMBER NOTHING ELSE…

A VBC roadmap should tell you what to build next, what can wait, and what evidence you need before progressing.

WORD TO THE WISE Do not let the calendar drive progression. Let performance, capability, and evidence make the decision. This appendix is referenced in Part V: Pilot, Learn, Improve, and Progress. © 2026 Synergy 3C – The Clinical Consulting Cooperative, LLC. All Rights Reserved.

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Appendix 33: Are We Ready to Advance? Decision Tool Purpose Use this tool to determine whether performance, capabilities, and organizational readiness support the next step in your Value-Based Care roadmap. Bring forward what you learned from the current phase, identify any gaps that could affect what comes next, and determine whether the evidence supports moving forward or whether additional work is needed ﬁrst.

1. Did We Demonstrate Results? Question Did we achieve our clinical and quality goals? Did we achieve our ﬁnancial goals? Did we achieve our operational goals? Did we achieve our patient experience goals? Did we achieve our provider/staff experience goals? Did the model demonstrate measurable value? Are results sufficiently consistent to support the next step?

Yes

Partial

☐ ☐ ☐ ☐ ☐ ☐ ☐

2. Can We Reliably Execute What Comes Next? Bring forward your prior capability assessment. Reassess only the capabilities that are critical to the next step being considered. Readiness Question Yes Needs Attention Are the critical capabilities required for the next phase functioning reliably? ☐ ☐ Can current workﬂows support the expected scope and volume? ☐ ☐ Can our workforce support the next phase? ☐ ☐ Can our data and technology support timely performance management? ☐ ☐ Can we identify performance problems early enough to intervene? ☐ ☐ Can clinical, operational, and quality oversight support the next phase? ☐ ☐ Do we understand the ﬁnancial requirements and risk? ☐ ☐ Are leadership and governance prepared for the additional accountability? ☐ ☐ Critical capability or execution gaps requiring attention:

3. What Are We Considering Next? Decision Question What is the proposed next step? Why are we considering it? What will it allow us to accomplish? What additional accountability, complexity, or risk will it introduce?

Response

4. What Must Be Addressed First? Critical Gap

How Will We Address It?

Owner

Build / Partner / Shared Service / Other

Required Before Progressing? ☐ Yes ☐ No ☐ Yes ☐ No

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5. Advancement Decision Based on the evidence reviewed above, what should the organization do next?

☐ STRENGTHEN

☐ SCALE

☐ EXPAND

☐ ADVANCE

☐ REPEAT MVP

☐ PAUSE / REASSESS

Decision rationale: What evidence supports this decision, and what remaining risk or uncertainty should leadership consider?

Actions Required Before the Decision Is Implemented Required Action

Owner

Target Timing

Executive decision-maker: ____________________________________ Decision date: ___________________________

✱IF YOU REMEMBER NOTHING ELSE…

Success in one phase does not automatically mean you are ready for the next. Advance when performance is reliable, critical capabilities can support the next step, and the additional accountability and risk are understood.

WORD TO THE WISE Don't let success create false conﬁdence. A successful pilot shows what can work under deﬁned conditions. Before expanding scope or accountability, make sure the organization can repeat, measure, and manage the performance reliably. The next step should be earned through performance and capability—not enthusiasm.

Related Tools Appendix 3: Foundational Capability Evaluation & Planning Tool Appendix 18: Performance Improvement Action Plan Appendix 24: Strategic Partnership Planning Worksheet Appendix 15: Financial Modeling & ROI Worksheet Appendix 11: Technology Inventory Worksheet • Leadership Alignment Discussion Guide

This appendix is referenced in Part V: Pilot, Learn, Improve, and Progress.

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The important thing is not where you begin, but that you begin intentionally. No two organizations begin from the same place. Some will launch a focused MVP with one payer and one patient population. Still others will continue refining capabilities already in place using the SAME process to refine. Successful ValueBased Care is built one capability, one workflow, one partnership, one lesson, and one patient at a time.

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