Transforming clinical care: Five tenets for sustainably remapping care delivery to patient needs
13 minutes
New possibilities for clinical care are rapidly progressing—as are patient needs and expectations. But the clinical operations of health systems aren’t keeping up.
While today’s healthcare dynamics add significant complexity and pressure to the current clinical enterprise, they also create a unique opportunity. Clinical discovery and advancements allow personalized prevention and treatment. Shifting sites of care enable better outcomes, experience, and lower costs. The systems and models for providing care must keep pace with these changes to ensure care that is safe, timely, effective, efficient, equitable, and patient-centered.1
We believe repositioning the clinical enterprise to tailor care delivery to evolving patient needs will unleash new possibilities for patient care and experience as well as health system sustainability and growth.
Clinical transformation isa fundamental change in how health systems deliver care to improve quality, safety, patient and provider experience, access, affordability, and equity. Health systems need to remap clinical structures, care models, team roles, and the supporting infrastructure to achieve this transformation.
Leading health systems will achieve clinical transformation by remapping their clinical enterprises around the distinct needs of their patient populations, focusing on population health status and outcomes.
Clinical transformation in action
A large midwestern health system knew it was time to rethink its care model. Patients were increasingly demanding more convenient and comfortable care. But the health system faced significant operational challenges, including capacity constraints and staffing shortages.
The organization needed to analyze its patient population to ensure its transformation would meet evolving patient needs and preferences while maintaining high-quality care and sustainability.
As we discuss the tenets for remapping care delivery, we share insights from the journeys of this health system and others.
Why it matters: Clinical operations must evolve with shifting patient populations and clinical advancements
The pace of advancement in care, including personalized medicine, targeted therapies, and digital modalities, is making traditional access and care delivery methods antiquated. As clinical paradigms rapidly change, they necessitate similar transformation of operations. For instance, diagnostic cardiac catheterization for many years required open heart backup. Now, with the increased use of transradial artery access for catheterization and intervention, the procedure is less invasive, leading to better outcomes, reduced length of stay, and a shift from the inpatient to outpatient setting.
Other recent advancements are creating the need for similar operational changes. For instance, GLP-1 therapies are reducing requests for bariatric surgeries by as much as 20%.2 Infusion volumes are expected to increasingly shift to ambulatory centers and the home, reaching 28% by 2027.3 Additional treatment advances mean that some grave conditions are now manageable chronic illnesses. Health systems need to understand changes at the population and site levels to plan resources that will meet demand.
The ability to scale rapidly, accelerating new clinical protocols and digital solutions, is a differentiating opportunity.
What’s next: Five tenets for clinical transformation
We discuss five tenets that transform the clinical enterprise, creating truly patient-centered care.
As patients increasingly turn to nontraditional providers for basic care, those accessing inpatient and ambulatory care are increasingly sicker, with more complex illnesses. This alters what they need from the health system and their experience of it. An intentional and holistic review of demand and capacity across your delivery network can help you determine where to expand capabilities and where to consider refocusing.
Where to start:
Examine the data to determine who is receiving services and where and how this has changed over the last several years. Create scenarios to project shifts in patient populations and demand for services over the next 3 to 5 years.
Survey your consumers to ensure you understand their needs and preferences, including their preferred site of care and how they access information and schedule visits.
Engage with community organizations to better understand your patients’ broader needs that drive how, where, and when they may access information and services.
Clinical transformation in action
One academic health system studied patient population needs against how patients were accessing care. It discovered that patients who traveled by bus would bypass primary care and urgent care clinics to receive care at the urban emergency department (ED) attached to the quaternary academic medical center.
Ambulatory and ED leaders examined patient zip codes and locations of utilization (e.g., system clinics, community clinics, urgent care, and EDs) and overlaid the locations with bus routes. They conducted a patient survey, which revealed that patients sought predictable, affordable transportation to the most comprehensive care location. Equipped with this data, the health system sought to improve patient experience and facilitate the right level of care by advocating for accessible and convenient bus stops at non-ED locations.
Use patient population data to change your care models* to meet evolving characteristics and needs. Your new care models should deliver the care patients need while improving caregiver engagement and expanding access and capacity. Using artificial intelligence, in-home check-ins, and remote monitoring can support the implementation of new care models (including care team composition, new technologies, and workflows) that will improve access to care and patient progression in both ambulatory and inpatient settings.
For example, incorporating a virtual registered nurse into the care model, along with communication and data collection tools and streamlined workflows, takes some administrative burden (e.g., admissions, testing, consults, and discharges) off the floor nurses, allowing them to focus on direct patient care. This modified care delivery can lead to improvements in patient satisfaction and care quality, as well as reductions in length of stay and provider burnout.
Where to start:
Take a fresh look at current care models to assess whether they need to change to meet patient needs. For example, as acute care increasingly shifts to the home, providing ED-level services in the home will require a new acute care model and potential changes to the physical ED.
Survey yourclinicians, front-line staff, and care teams to understand which part of the care model is working well and which needs are not met. This feedback can inform the design of new care models.
Prioritize required care model changes based on available implementation resources and requirements. For example, consider prioritizing clinical areas in which provider burnout is most prominent, such as primary care, or areas that could benefit most from tech-enabled solutions.
Clinical transformation in action
Brigham and Women’s Faulkner Hospital developed a postoperative model to ensure age-appropriate care that would address issues with postoperative delirium and complications and 30-day readmission rates among older patients. The Superior Surgical Treatment for Seniors Pathway involves a multidisciplinary care team, including nursing, physical therapy, pharmacy, and dietary interventions.
The program screens patients aged 65 years or older for frailty risk. Patients deemed frail or at risk for frailty receive geriatric-centered care to prevent delirium and improve function. Interventions tailored to the needs of this population include a sleep–wake cycle during which patients are allowed uninterrupted sleep if medically appropriate and are encouraged to get out of bed for meals and ambulate.
Close collaboration between providers and the pharmacy has helped this population recover from procedures while avoiding the mental and physical deterioration that can result from a hospital stay.
*Care model: The purposeful and intentional alignment and coordination of resources required to deliver a set of services and experiences that produce desired outcomes.
Health systems can embed high reliability into their new care models. Embracing the principles of resiliency enables the models to maintain or improve the level of rigor and engagement needed to ensure safety and continuous improvement, no matter where care is delivered. Establishing systems and a culture of high reliability is especially critical when providers and staff are delivering care in nontraditional settings.
Leading healthcare organizations establish patient safety and operational goals and targets at the board level, cascade these goals to the patient level, and foster the partnership of physicians and nurses to achieve these goals. Patient care teams utilize clinical protocols, defined workflows, and effective communication, giving them a common understanding and plan for patients’ clinical and psychosocial needs as well as potential health disparities and barriers to care. Achieving the desired outcomes for your patient populations may require your organization to rethink clinical guidelines, care plans, and access paradigms.
Where to start:
Engage your organization to ensure all staff—from the board to the front line—are aligned on methodology and benchmarks. Providing clarity on the measures used to assess progress is critical.
Build in accountability and visibility by empowering front-line teams to speak up about risks and solutions.
Leverage actionable data to design evidence-based and practical care protocols to reduce variation and enhance adoption and long-term sustainability.
Clinical transformation in action
At one leading health system, patients with heart failure may be discharged early from the acute care setting to continue treatment under a hospital at home model. A dedicated care team of physicians, nurses, and remote monitoring specialists follows standardized protocols to manage care seamlessly and deliver hospital-level care.
This nontraditional care environment presents unique vulnerabilities and nuances that could increase the chances of inadvertent errors. To mitigate this, the team leverages real-time data and evidence-based care plans, closely monitors vital signs, adjusts medications promptly, and intervenes early to treat symptoms before they escalate into complications.
The team regularly presents its work to the health system’s board as part of its quality outcomes report, which includes challenges to delivering high-quality, safe care in the home. A structured alignment and accountability model cascades feedback from the board and senior leaders to front-line teams, enabling them to engage in facilitated dialogue and expeditiously refine care protocols.
As a result, patients with heart failure receive a consistently high standard of hospital-level care at home, with fewer readmissions, increased patient satisfaction, and improved outcomes.
Many clinical staff are already overburdened or experiencing burnout. Changing care models can shift expectations for your workforce, creating further stress. Health systems must ensure their teams are invested in the change and appropriately resourced, trained, and supported to deliver care in new sites for sicker, more complex populations. Properly investing in your workforce can create a more satisfying experience and avoid adding to their existing challenges.
Where to start:
Assess the current state of your clinical workforce by engaging team members via focus groups and surveys to understand what is working well and identify issues that impact them daily. Then, commit to making changes and communicating the results.
Reinforce the connection to the mission by identifying ways to encourage team members in their desire to help others. Hardwire these into daily activities, such as leadership rounds and meeting agendas.
Improve the daily experience by addressing care team members’ daily frustrations and redefining roles so everyone can work at the top of their license. Leveraging technology (e.g., ambient listening, prescriptive analytics, and remote monitoring) can enable greater efficiency and effectiveness.
Reinforce accountability for results by transparently reporting performance against goals to engage care team members in achieving organizational goals and reinforce leaders’ commitment to those goals.
Clinical transformation in action
One large health system aimed to ensure a strong workforce amid significant care model changes. It invested in training, technology, and workforce flexibility to prepare its employees for the new care delivery methods. This included upskilling nurses and physicians to provide virtual care, equipping staff with remote monitoring tools, and partnering with home health providers to extend care beyond traditional hospital settings. Front-line staff also had a voice in shaping new care models, ensuring that the changes aligned with their expertise and workflow needs.
The health system fostered continuous learning through cross-training and professional development programs, preparing employees for shifting roles in hybrid care models. It implemented flexible work arrangements, mental health support, and leadership development programs to address burnout and job dissatisfaction. By providing clear career pathways, competitive compensation, and opportunities to work in emerging fields, such as telehealth, the organization retained talent while attracting new professionals excited about the evolving healthcare landscape.
It also leveraged real-time data and employee feedback loops to refine care delivery, improve job satisfaction, and optimize team workflows. By prioritizing workforce well-being, adaptability, and ongoing education, the organization successfully navigated change while maintaining high-quality patient care.
Implementing new care models can be a risk and an opportunity. Return on investment is key. To ensure sustainability, optimize reimbursement, payment, and compensation models as well as facilities and technology. Appropriate metrics and a monitoring system allow governance teams to monitor progress and ensure ongoing effectiveness and value.
For example, multi-hospital health systems typically provide higher acuity care at one or two hospitals, while other facilities are community or critical access hospitals. However, higher acuity hospitals often operate at or above capacity as they also provide lower acuity care to their local communities. Establishing a command or transfer center that has purview across the system and understands local hospitals’ investment needs (e.g., expanded specialist coverage, tele-consults) supports caring for patients at the most appropriate facility. This ultimately reduces the overall cost of care while improving quality and patient experience.
Where to start:
Understand the margin impacts of specific patient populations by evaluating how margins change across populations and settings of care, such as the difference between caring for a low-acuity patient at a community hospital and a quaternary care hospital or between in-person and virtual primary care visits.
Assess the financial implications of new care settings to decide whether new models of care (e.g., care at home) are less expensive and whether they impact capacity to improve access.
Identify the financial benefit of quality improvements by examining how improvements such as increased quality of care, reduced length of stay, and increased consumer satisfaction can provide financial benefits.
Focus on performance by defining the desired outcomes (e.g., financial, efficiency, quality, and experience) and continuously monitoring progress toward those goals.
Clinical transformation in action
One health system in an expensive real estate market decided to invest in home health as a strategic reallocation. Leaders holistically reconsidered provider placement and their physical facility footprint. The shift to home health for specific populations enabled the health system to close one physical facility, reduce the size of another, and reallocate resources based on the evolving needs of its patient population.
Transform your clinical enterprise for far-reaching results
Health systems face mounting pressure to meet shifting patient needs and ensure caregiver well-being while managing costs and maintaining quality. Transformative care models—such as workforce reskilling, geriatric-centered postoperative care, and home-based care—offer an innovative solution. Health systems can leverage technology and data-driven insights to optimize outcomes and ensure sustainability. These five tenets can redefine how you see your patient population and your care models, putting the patient at the center of care and future-proofing your health system.
Clinical transformation in action
The midwestern health system highlighted in the introduction of this piece focused on at-home care and relied on the five tenets we discussed to improve the care model in its community and more broadly.
Analysis of patient satisfaction surveys, hospital utilization metrics, clinical outcomes, and cost assessments revealed surprising insights: Older adults were more receptive to telehealth than expected, home-based patients generally had lower infection rates, and patients strongly preferred personalized attention over traditional hospital stays.
Financial analysis showed that home-based care reduced costs for patients and payers, lowered readmission rates, and shortened recovery times—challenging assumptions that inpatient care is always superior and reinforcing the viability of alternative care models.
The health system leveraged remote monitoring, virtual check-ins, and in-home clinical visits to safely manage conditions such as pneumonia, heart failure, and post-surgical recovery. By partnering with home health providers and leveraging digital health technology, it provided high-quality, patient-centered care while alleviating pressure on inpatient facilities.
As a result, the health system successfully implemented and expanded its home-based acute care program, demonstrating how innovative models can enhance patient outcomes, improve satisfaction, and reduce healthcare costs. This success led to broader adoption of home-based care across the industry—influencing how health systems think about delivering high-quality, accessible, cost-effective care.
9 “Preliminary medians—Revenue growth drives improved profitability,” Moody’s Ratings Sector Profile for Not-for-Profit and Public Healthcare, April 3, 2025.
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