INTEGRATING SERVICE DELIVERY MODELS

The Ariadne Labs Primary Health Care Program is studying best practices in integrating service delivery models to advance comprehensive, coordinated, continuous, and people-centered care. 

We are developing and testing models to improve management of chronic disease — both communicable and non-communicable — in low- and middle-income countries.The team is studying how patient engagement models may improve patients’ self care as well as care management and working to improve care coordination for medically complex patients. 

Our ongoing research aims to generate evidence and scalable insight on high-performance models for how PHC services are provided at community levels, and how local primary care systems can provide coordinated access to comprehensive secondary, tertiary, and whole of person care.

PROJECTS

Improving Care for hypertension: BP Sawa

BP Sawa (2024) — a hypertension pilot program in Nairobi, Kenya— was rolled out by Penda Health in partnership with Ariadne’s Primary Health Care Program, supported by Endless Network. BP Sawa is an innovative clinical delivery pathway for the treatment and management of patients with hypertension. The intervention was designed through an intensive patient journey mapping and co-design process which brought together key clinic staff, leadership, researchers, and implementation and design specialists. BP Sawa aims to demonstrate the power of shifting to a proactive, PHC-centered health delivery model in the pursuit of more person-centered, high-quality care.

The female therapist gestures while she talks to the unrecognizeable woman

Scaling Pediatric Behavioral Health Integration: TEAM UP

For the TEAM UP Scaling Project (2022-2023), Ariadne Labs applied our expertise in spreading health care interventions to recommend a scaling roadmap for the Transforming and Expanding Access to Mental Health Care in Urban Pediatrics (TEAM UP) project. This initiative trains federally-qualified health centers in its pediatric behavioral health integration model of care. 

Ariadne Labs worked closely with TEAM UP’s funders —the Richard and Susan Smith Family Foundation and The Klarman Family Foundation — and implementer —Boston Medical Center — to develop a deep understanding of TEAM UP’s model of care. We interviewed clinical and administrative staff at implementation sites; conducted a business and policy landscape analyses; and applied implementation science frameworks. We then developed  detailed recommendations on how to optimize the model for scale and developed an implementation plan.

Building Equity in Telehealth: Crosswalk Telehealth

Crosswalk Telehealth (2021-2023) was a research project led by Ariadne Labs and Boston University School of Public Health (BUSPH) with funding from the Donaghue Foundation and the Robert Wood Johnson Foundation. The project aimed to determine and establish equity-based telehealth best practices for Medicaid-enrolled patients with chronic conditions. Ariadne Labs and BUSPH used data from electronic health records, insurance claims, and patient surveys to evaluate how telehealth affected the quality, cost, and equity of care for patients with chronic diseases. In addition, we studied how effects may have varied by race, ethnicity, and language. Ariadne also identified scalable best practices for optimizing value, quality of care, and equity of care through telehealth.

Tallinn Old Town entrance, Estonia.

Enhanced Care Management in Estonia

The Estonia Enhanced Care Management (ECM) Project (2016-2020) was a collaboration between the PHC Program, the Estonian Health Insurance Fund (EHIF), and the World Bank. The purpose of the project was to build and pilot a program to improve care coordination and strengthen Estonia’s primary health care system. The resulting ECM package included interventions to identify high-risk patients through risk stratification, develop care management plans for these patients, proactively link care providers, and cultivate multidisciplinary primary health care team models of care. 

In 2020, Ariadne Labs worked with EHIF and the World Bank to apply the lessons learned during an initial pilot to nationally scale the program, with the goal of ultimately reaching all 800 of Estonia’s primary care practices.