Vandalia Care, an accountable care organization (ACO), had been successfully developed as part of Vandalia Medical Center (VMC), but the new ACO's leadership had become concerned. Specifically, they worried that their mission to reduce care costs while improving the health of the population was at risk. In the six months since Vandalia Care had been established, the number of patients served had increased, but VMC was having difficulty determining whether and how the ACO model was having an impact on the health of its population.

VMC had an electronic health record (EHR) that was operational in both inpatient and outpatient settings, but not all providers could access all elements of the EHR. Now that Vandalia Care had been implemented, a new problem arose with respect to data. Vandalia Care had associated hospitals and providers, but because of the way ACO contracts were written, patients attributed to the ACO were not required to use those facilities and clinicians. As a result, when patients attributed to Vandalia Care visited providers external to the ACO, data about those visits were virtually impossible to collect. Considering that Vandalia Care's goal is to improve the health of the entire ACO population, lack of access to the comprehensive health records of all attributed patients was problematic.

Lindsey Dillow, the new manager of care coordination for Vandalia Care, wanted to help solve this problem. Drawing from recent research on ACO development (McAlearney, Song, and Hilligoss 2017), Dillow believed that Vandalia Care patients, like other ACO patients, did not know they were actually part of the ACO. Patients might be loyal to their primary care physicians, but when they needed specialty care or hospitalization, they went wherever they wanted to go, regardless of whether the setting was part of Vandalia Care. As a result, Dillow did not know these patients had sought services outside the ACO until she received claims data several months after the admission or visit, thus significantly compromising her ability to coordinate care. Further, costs that could have been controlled via ACO contracts with specialists, hospitals, and even skilled nursing facilities were left unchecked.

Vandalia Care's launch had included a mass mailing to members of the community, but Dillow believed more needed to be done to engage patients and community members in improving their health. She knew that the ACO's leadership was open to supporting a major initiative to connect with the community, so she needed to carefully consider her strategy. Dillow recognized that a true focus on population health management had to be less about branding the ACO and more about engaging consumers and encouraging them to care about their health. In particular, she believed that an important element of this outreach had to focus on connecting physicians with community members. She wondered whether focusing on a particular segment of the population firstchildren, for instancemade sense, or whether staging her outreach plan by geographic area or community was a better alternative. Dillow had access to the Vandalia EHR to inform her plan, but she needed to figure out what to do first.

1) How could the EHR be used to improve population health management?

2) What kinds of community outreach might be effective for Vandalia Care? What kinds of outreach might be perceived less favorably?