Building a High-Performing Care Management and Population Health Model in a Fully Capitated Primary Care Group:

An Evaluation of HealthTeamWorks’ Implementation Approach
Resource Type: 
  • Case Study

    Abstract

    This case study evaluates the collaborative development and implementation of a comprehensive care management (CM) and population health model by HealthTeamWorks in partnership with a fully capitated primary care group in the Midwest. The project employed systems-thinking and adaptive leadership to enhance integrated care delivery, improve clinical outcomes, and develop a sustainable care management infrastructure. Through a phased workplan involving training, risk stratification, piloting, and implementation, the intervention demonstrated promising outcomes in workforce capacity building, patient engagement, and data-informed care delivery. This case study outlines the methodology, implementation process, outcomes, and implications for scalable population health strategies. 

    Introduction

    As health systems shift toward value-based care, primary care organizations face increasing pressure to address complex patient needs using scalable, sustainable approaches. Care management has emerged as a critical strategy to achieve improved health outcomes and cost reduction, particularly when combined with population health infrastructure. This case study presents HealthTeamWorks’ work with a fully capitated primary care group in the Midwest to design and implement such a model. 

    Objectives
    • Establish an integrated and sustainable care management infrastructure.
    • Equip Nurse Care Managers (NCMs) with tools and training for top-of-license care delivery.
    • Design and implement a data-informed risk stratification model to guide interventions.
    • Evaluate the effectiveness of the care management model in improving population health outcomes and enabling long-term scalability.

    Methodology and Approach

    HealthTeamWorks employed a systems-thinking approach, leveraging adaptive leadership and Plan-Do-Study-Act (PDSA) cycles. Co-design methodology was central, incorporating input from executive leaders, frontline staff, and data analysts. 

    Adaptive Leadership

    Adaptive leadership provided a guiding principle for engaging stakeholders in navigating complex, non-linear change. It emphasized distributed leadership, iterative learning, and the importance of distinguishing technical fixes from adaptive challenges. Leaders at multiple levels were supported in creating space for innovation, managing resistance, and co-creating sustainable solutions. 

    Flipped-Classroom Learning for CM Training

    To accelerate adult learning and reinforce knowledge application, HealthTeamWorks used a flipped-classroom model. Nurse Care Managers first completed foundational training asynchronously through the Essentials of Care Management online curriculum, followed by live coaching sessions that contextualized training content to real patient scenarios. This approach emphasized active learning, reflection, and iterative skill development. 

    Co-Creation with Frontline Staff and Leaders

    HealthTeamWorks engaged both executive leadership and frontline care team members, particularly NCMs, in co-designing care management workflows, tools, and performance metrics. This collaborative approach ensured relevance, increased buy-in, and supported sustainable implementation by addressing real-world operational constraints and opportunities. 

    Data Integration and Visualization

    The project emphasized the consolidation of disparate data sources—including EHR and claims data—into a centralized, actionable Risk Stratification Dashboard. This visualization tool enabled NCMs and care teams to prioritize outreach, track risk over time, and inform quality improvement activities. Data integration was essential for proactive population health management. 

    Continuous Quality Improvement (CQI) and PDSA Cycles

    A foundational component of the implementation strategy was the use of CQI tools, especially Plan-Do-Study-Act cycles, to pilot interventions, gather feedback, and refine processes in real time. These cycles enabled the team to test small changes, scale successful practices, and iteratively build a robust care management infrastructure responsive to emerging needs. 

    Intervention Components

    Discovery & Design

    This initial phase involved stakeholder interviews, review of existing clinical and claims data, and facilitation of strategy sessions with executive leaders. The goal was to understand the organization’s population health needs and establish a shared vision for care management. A Care Management Scorecard was drafted to align metrics with organizational goals. 

    Workforce Development

    HealthTeamWorks prioritized equipping Nurse Care Managers with the competencies necessary for high-functioning CM. This phase included asynchronous training via the Essentials of Care Management online modules and synchronous weekly coaching sessions. The flipped-classroom approach allowed for skill application in real-time patient scenarios and reinforced team learning. 

    Infrastructure Development

    This phase focused on building the technical foundation for CM, including the development of a Risk Stratification Dashboard integrating EHR and payer data. In tandem, Standard Operating Procedures (SOPs) were drafted to guide CM enrollment, outreach, documentation, and role delineation. Standing orders were introduced to streamline NCM-initiated referrals based on risk scores. 

    Pilot Implementation

    Care management processes were piloted in two practice sites selected for their variability in provider engagement and operational readiness. This phase tested newly developed tools and workflows, utilizing PDSA cycles to make real-time adjustments. Feedback from NCMs and site leaders was used to refine SOPs and improve CM encounter documentation. 

    Full Rollout

    With lessons learned from the pilot, CM was implemented across all practice sites. This stage included in-person training sessions, distribution of updated tools, and continued coaching. HealthTeamWorks supported ongoing adjustments and reinforced alignment with the CM Scorecard to ensure consistency across locations. 

    Sustainability Planning

    The final phase embedded continuous improvement processes into the organization’s structure. Quarterly reviews of CM Scorecard data, regular feedback loops with NCMs and care teams, and alignment with evolving strategic goals supported the long-term viability of the CM infrastructure. Emphasis was placed on capacity-building and adjusting CM practices based on population needs and performance trends. 

    Figure 1 Care Management Implementation Journey
    Data Collection

    Data collection for this engagement was multifaceted, integrating both quantitative and qualitative measures to capture the full scope of implementation and its impact. These data streams provided the basis for ongoing evaluation and informed decision-making throughout the intervention. 

    Enrollment Data

    Capturing the number of patients identified, contacted, and enrolled in care management allowed HealthTeamWorks and the participating organization to monitor uptake, assess outreach effectiveness, and identify trends across practice sites. This dataset helped quantify engagement at both the site and population level. 

    Scorecard Metrics

    These included lead and lag indicators from the Care Management Scorecard such as improvement in clinical outcomes (e.g., blood pressure control, HbA1c reduction), NCM workload and caseload size, and post-acute outreach rates. These indicators provided benchmarks for performance and allowed for the evaluation of alignment between care management efforts and organizational goals. 

    Coaching and Training Participation Records

    Documenting NCM participation in online modules, synchronous coaching, and in-person sessions helped assess the reach, intensity, and consistency of workforce development efforts. Attendance data and feedback were used to adapt training to meet learner needs and operational realities. 

    Qualitative Feedback from NCMs and Leadership

    Anecdotal stories, thematic analysis from debrief sessions, and stakeholder reflections enriched the understanding of both the implementation process and impact. These qualitative inputs highlighted adaptive challenges, surfaced barriers and facilitators, and helped inform iterative improvements. 

    Together, these data elements offered a holistic view of the care management implementation process and supported real-time learning and long-term evaluation. 

    Results

    The results from this implementation effort reflect meaningful progress in building a sustainable care management infrastructure while advancing the goals of population health. The five domains below highlight both the quantitative achievements and qualitative transformations observed throughout the project. 

    Figure 2 Care Management Implementation Results Domains
    Training and Capacity

    All Nurse Care Managers (NCMs) successfully completed the Essentials of Care Management and Intermediate Care Management training, including asynchronous coursework and live coaching. This full participation rate signifies strong engagement with professional development and reflects leadership support for capacity-building. Weekly coaching sessions allowed NCMs to apply new knowledge in real time, build confidence, and enhance their skills in patient engagement, goal setting, and interdisciplinary communication. Over time, the training contributed to greater consistency in CM practices across sites. 

    Risk Stratification

    The development and integration of the Risk Stratification Dashboard marked a significant achievement. By combining EHR and claims data, the dashboard supported real-time identification of patients at highest risk. NCMs and clinical leaders used the dashboard to prioritize outreach, adjust staffing and caseloads, and evaluate program reach. This tool became central to the care team’s ability to deliver proactive, data-informed interventions tailored to population needs. 

    Figure 3 Risk Stratification Pyramid
    Table 1 Risk Stratification Category and Intervention Type Table

    Risk Category

    Intervention Type

    High (8–15)

    NCM-Led Care Management

    Moderate (4–7)

    Health Coach/Short-Term CM

    Low (0–3)

    Preventive Care/Self-Management

    Patient Engagement

    There was a measurable increase from 49 patients enrolled in care management following full implementation in January 2023 to 181 patients enrolled one year later. The combination of structured outreach protocols, risk-informed targeting, and person-centered coaching led to stronger patient activation and follow-through. NCMs reported increased ability to engage patients around SMART goals and promote continuity of care across care transitions. These engagement efforts were essential in shifting the care team’s focus from reactive to preventive and longitudinal care. 

    Real-world success stories illustrate the depth of this engagement. Patients reported improved understanding of their insurance coverage, medication adherence, and self-management practices. In several cases, engagement with CM led to notable clinical outcomes, such as reduced A1C levels (e.g., from 13.9% to 5.3%), significant weight loss (e.g., up to 80 pounds), improved blood pressure control, and reduced emergency department use. One patient, previously identified as the highest-risk member in the system, decreased both hospitalizations and their risk score through regular monthly visits with their provider and NCM. 

    Patient narratives also highlighted increased confidence, empowerment, and trust. One patient described their CM experience as a “game changer,” while others felt newly supported in managing chronic conditions, securing housing, or accessing affordable medications. These outcomes underscore the impact of integrating social determinants of health and mental health referrals into the CM workflow. 

    SOP & Infrastructure

    The refinement of standard operating procedures (SOPs) during pilot testing and rollout contributed to a streamlined and replicable model. SOPs addressed documentation, referral workflows, and NCM task responsibilities. The clear delineation of processes improved efficiency, ensured role clarity, and enhanced cross-functional coordination. As these practices became standardized across sites, the infrastructure supported a culture of shared accountability and operational alignment. 

    Leadership & Alignment

    The CM Scorecard emerged as a strategic tool for aligning frontline activities with executive goals. Scorecard metrics were routinely reviewed in leadership meetings and incorporated into performance discussions. This alignment helped institutionalize care management as a core function within the organization’s value-based care strategy. It also reinforced NCMs’ contributions as central to achieving quality, cost, and equity goals. 

    Together, these results demonstrate how a structured and collaborative implementation approach can advance care team capacity, population health infrastructure, and organizational alignment in support of whole-person care. 

    Discussion

    This intervention underscores the importance of aligning leadership vision, frontline capacity building, and data infrastructure to support sustainable care management. Nurse Care Managers play a critical role when empowered with training and technology. The use of risk stratification facilitated efficient targeting of resources. The study also highlights challenges such as workload transitions and variability in adoption, which were addressed through coaching and stakeholder engagement. 

    HealthTeamWorks’ implementation of a care management infrastructure and population health model in a fully capitated setting demonstrates a viable framework for organizations transitioning to value-based care. Key elements include co-designed strategy, workforce development, and use of real-time data to inform risk-driven interventions. Further research may explore long-term patient outcomes and cost savings attributable to this approach. 

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