2020 Acclaim Award Recipient

St. Elizabeth Physicians
St. Elizabeth Physicians has incorporated AMGA’s High-Performing Health System™ attributes into their multispecialty practice in the following ways:


  • St. Elizabeth Physicians was selected for participation in Comprehensive Primary Care Plus (CPC+), a five-year advanced primary care medical home model.
  • They were enrolled in Track 1 of the Medicare Shared Savings Program and are currently taking accountability for the quality and cost of care of 60,000+ traditional Medicare members.
  • To measure patients' perception of the care provided by their physicians, St. Elizabeth Physicians surveyed patients using the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) survey. Responses are used to develop star ratings for providers, and comments about providers are made available to the public on St. Elizabeth Physicians’ website.
  • The organization introduced quarterly Patient Family Advisory Councils in each of their primary care practice locations, enabling patients to provide vital feedback to providers and administrators on how the organization is meeting their needs.

Broadening Lens to Focus on Continuum of Care

  • St. Elizabeth Physicians developed and implemented a Clinical Transformation Division—comprised of Ambulatory Care Management, Service Excellence, Quality Transformation & Process Improvement, Quality Payment Programs, and Value Based Performance Departments—to support the Primary Care, Medical Specialty, and Surgical Specialty Divisions in their transformation to value-based care models. This department serves as St. Elizabeth Physicians’ population health infrastructure.
  • The organization implemented of a five-year plan called “Engrained in Excellence.” In each of its five years, the Engrained in Excellence program included monthly interventions and strategic deployments of processes, resources, and tools to engage patients in their path to better health.
  • St. Elizabeth Physicians developed and implement new policies, procedures, and protocols to serve patients with chronic and acute pain, as well as for serving patients with a primary or secondary opiate use disorder/substance use disorder diagnosis.

Care Coordination

  • St. Elizabeth Physicians decreased avoidable emergency department visits by centralizing the outreach of all emergency department visit follow-up phone calls with members of the care management team who worked with patients to identify the root cause of their use of the emergency department and educated them on appropriate use of the emergency department.

Compensation Practices

  • A Value-Based Performance Department was developed and staffed with clinical and non-clinical associates responsible for the successful management of value-based contracts covering nearly 170,000 patients.

Efficient Provision of Services

  • St. Elizabeth Physicians created a process improvement department. It is led by a former Toyota employee who leverages their experience in Lean and the Toyota Production System to develop quality improve initiatives and workflows to enhance EHR efficiency.
  • Annual wellness exams were provided to 71.8% of their eligible patient population in 2018, and more than 80% of eligible patients in 2019. Patients completing annual wellness exams experience costs 12.8% lower than patients who do not complete them.
  • The organization began offering Low Dose Computed Tomography (LDCT) screenings for lung cancer in 2015. They have since screened more than 11,000 patients for lung cancers, finding a cancer in one out of every 62 patients screened. Patients screened for lung cancer using LDCT often have their cancers identified much earlier than patients whose cancers are detected without LDCT, and lung cancers caught in Stage I have a cure rate that can exceed 90%.

Improve Access to Care

  • St. Elizabeth Physicians Implemented asynchronous eVisits to improve patient access, decrease avoidable in-person and emergency department visits, and provide an innovative way for patients to receive care.
  • Five Urgent Care Centers maintain evening hours to provide access to patients seeking care outside of traditional practice hours.

Organized Systems of Care

  • St. Elizabeth Physicians developed a clinically integrated network with another health system in their market, which led to improved access to care, decreased cost of care, and an opportunity for collaboration in the management of more than 60,000 traditional Medicare and 7,000 Medicare Advantage patients.
  • Patient Perception of Care (PPOC) surveys were implemented to measure, track, and respond to patients.

Quality Measurement and Improvement Activities

  • The organization thoroughly reviewed more than 17 payer contracts and internal physician incentive compensation plan documents to reduce quality measures of focus from 84 to 12. Each of these measures is defined by National Committee for Quality Assurance (NCQA), National Quality Forum (NQF), or Healthcare Effectiveness Data and Information Set (HEDIS) standards, and enables the organization to narrow the focus its improvement efforts.
  • St. Elizabeth Physicians aligned the quality initiatives associated with their provider incentive compensation program to arrive at a consistent group of five quality metrics that were shared across all specialties. These metrics are colorectal cancer screenings, breast cancer screenings, hypertension control, hemoglobin A1c control, and diabetic retinopathy screening completion.
  • They developed a comprehensive, multidisciplinary ambulatory care management program as part of the Center for Medicare and Medicaid Innovation’s (CMMI’s) Comprehensive Primary Care Initiative.

Technology and Evidence-Based Medicine

  • St. Elizabeth Physicians developed a direct interface between their EHR and Exact Sciences, the maker of Cologuard, to enable the bulk ordering and interfacing of results via the EHR. The organization is one of only two in the world to have developed this interface with Exact Sciences, and since inception, they have used their data registry and electronic medical record to bulk order more than 5,000 Cologuards for eligible patients.
  • They invested nearly $300,000 in handheld diabetic retinopathy cameras that were deployed to each primary care location and the organization’s Regional Diabetes Center. Since inception, more than 10,100 patients have been screened for diabetic retinopathy in their primary care or endocrinologist’s office and had the result interpreted via telemedicine by an ophthalmologist.