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Home-Based Primary Care Patient Selection Process  

Identifying additional patients or sub-populations of patients that would benefit from inclusion in Atrius’ home-based primary care model through predictive modeling of cost of care and number of hospitalizations.


Reducing avoidable “leakage” through reduction of repatriable claims paid to outside of Atrius by development of various methods to understand leakage behavior and patterns, followed by identifying and implementing the most promising method/approach to prevent, detect, and mitigate where possible.




Inappropriate ED Utilization, Convenience Care Continuity      

Reducing inappropriate pediatric utilization of EDs and associated costs through design of an evening cross-coverage process and use of CQI methods to implement and refine solutions.



Patient Falls

Reducing cost and health consequences of falls by designing patients and families into a prevention reliability model.



Perioperative Supply Chain & Inventory Management

Reducing perioperative supply chain and inventory costs through PAR level optimization, preference card standardization, and reducing unnecessary waste.

Resident Team Scheduling - Primary Care Continuity 

Increasing continuity of care, in terms of patients seeing their primary care provider or someone from their ‘teamlet,’ by way of an improved scheduling system that increases coverage of teamlets and access. Click here to view triple aim project summary.



SNF Care Incentive Design 

Reducing rehospitalization costs by designing a financial model that rewards skilled nursing facilities (SNFs) for desired outcomes.




Capacity Consolidation

Reducing the amount of time patients spend in the waiting room, better satisfying staff, and allowing Dana Farber to increase the amount of patients that can be seen each day.

Bone Marrow Transplant Diagnostic Tests

Creating a standardized measurement technique method, allowing the Quality Improvement team to identify further process improvement opportunities, and monitoring sustained changes.



ED Opioid Abuse 

Recognizing, preventing, and reducing adult Substance Use Disorder in the community by bridging the communication of patient Opioid treatment for back pain between the ED and PCPs or Specialists for at least 20% of non-admitted patients seen in the ED and reinforcing education of longer term pain management solutions with distribution of patient education materials for at least 25% of repeat ED patients last seen within 30 days.

ED Optimal Redistribution

Mathematical modelling and optimizing emergency care network, allowing Hallmark to justify closing one of their EDs without compromising care or over-capacitating or underutilizing other locations in the network. Providing sufficient, emergent care to the community at a lower cost.

Surgical Site Infection

Reducing cost and health consequences of surgical site infections using bundle compliance methods.

GeriPsych Falls

Reducing cost and health consequences of falls by designing patients and families into prevention reliability model.





Outpatient Appointment Access

System wide task force to reduce poor access.

GI Procedure Room Utilization

Using computer simulation to consolidate shared space between multiple specialties to reduce costs and improve utilization and flow.

Specialty Clinic Efficiency

Using process improvement methods, predictive modeling, no-show scheduling, and computer simulation to reduce costs from poor room utilization, overtime, and lost RVUs.



Hospice Rehospitalizations

Data analysis and predictive modeling to identify at-risk hospice patients for rehospitalizations to reduce associated costs.

System Utilization Predictive Modeling

Using predictive models of patient flow between home hospice and inpatient unit occupancy to reduce associated staffing and overflow costs.


COPD Readmissions Reduction        

Reducing COPD 30-day readmissions using a tool to assess and visually display effectiveness of interventions to improve COPD outpatient care management.

Colorectal Surgery Length of Stay

Reducing readmissions for colorectal surgery patients using a risk-based decision support tool to guide timing of discharge/care transition prep/planning.



ED Efficiency Tool

Reducing per-ED costs, patient flow delays, and non-timely care metrics by developing and implementing a performance dashboard with embedded mathematical methods for performance issue detection, trending, and predictive modeling.



Central Line Infection (CLABSI)       

Reducing the number of central line infections in critical/intensive care units and associated length of stay, related complication outcomes, and related costs.

Neurology Referrals

Reducing total number of unnecessary appointments resulting from inappropriate referrals and their corresponding cost.

Neurology Department Appointment Access

Improving appointment access in 14 divisions of the Neurology Department. Improving access will result in reducing no-shows and better resource (providers) utilization i.e. lower specialists’ idle time.





Improving Diabetes Patient Care

Identifying reasons for non-adherence to recommended diabetes care components for Medicare patients and the associated reasons for non-adherence; developing systematic interventions to address each of the identified potential causes of non-compliance with the goal of improving individual care bundle component and overall composite compliance rates using FMEA and Reliability Science frameworks.

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