Patient engagement strategies (PES) are behavioral and relational in nature. They include using patient-reported outcomes (PROs) for treatment monitoring, using shared decision-making (SDM) tools, and training clinicians in motivational interviewing. The long-term maintenance of PES by primary care practices requires substantial frontline effort, adaptation to workflow, and supportive organizational cultures. To measure the adoption and exnovation of PES by adult primary care practices and to identify organizational factors associated with the count of exnovated PES, defined as the deliberate or passive removal of previously adopted strategies. Retrospective longitudinal cohort study. A national cohort of US adult primary care physician practices (n = 714), spanning two waves of the National Survey of Healthcare Organizations and Systems (NSHOS I: 2017–2018 and NSHOS II: 2022–2023). The outcome was the number of PES that the practice exnovated, on net. Independent variables included baseline measures and change scores for the practice’s innovation culture and health information technology functionalities. Practice-level adoption of ten PES increased slightly from a mean of 4.2 (SD = 2.5) to 4.8 (SD = 2.7). Nearly half of practices (46

This article describes how two complementary theories from complexity science can guide the successful design and implementation of integrated systems of health and social care for older adults who need multiple forms of care. Specifically, it describes two related theories: "complex adaptive systems" (CAS) theory and "relational network theory" (RNT), which provide overlapping frameworks for understanding the structure and dynamic function of care systems and their components. The article begins by showing how these theories can guide the integration of the structures, people, and processes that provide care to older adults with multiple care needs. Then, to illustrate their application, it describes the early years of the All-Inclusive Care for Older Adults ("ALICE") program, which has cocreated and comanaged an evolving health and social care system for an aging population in New South Wales, Australia. As other populations of older adults around the world expand, such effective integration of multi-faceted care will be necessary to optimize their well-being and quality of life. Future applications of CAS and RNT to the design and implementation of integrated health and social care promise to improve the quality and the effectiveness of the care of other older populations that need multiple forms of care.

Abstract Background Primary care forms the basis for valued outcomes in health systems, including population health, high quality care, and reduced health expenditures. However, the primary care system in the United States (US) faces many difficulties, including financial pressures and clinician burnout that accelerated following the Covid-19 pandemic. This study examines the ability of primary care practices to adapt to post-pandemic challenges using a lean management system for quality and process improvement. Methods We used data from the National Survey of Healthcare Organizations and Systems II, a nationally representative sample of 1,245 physician practices located across the US. We first described the status of lean implementation among these primary care practices. We then conducted bivariate analyses followed by multivariate logistic regressions to examine relationships between lean implementation and outcomes of interest, including pandemic response activities, financial performance after the pandemic, and impacts of workforce shortages on patient care. Results Practices that adopted lean management were significantly larger in size ( p < 0.05), affiliated with a health system or federally qualified health center ( p < 0.0001), had a higher percentage of revenue from Medicaid ( p < 0.0001) but lower percentage from Medicare insurance ( p < 0.05), participated in more capitated payment arrangements and Accountable Care Organization contract types ( p < 0.01), and were more evenly distributed across geographic regions of the country ( p < 0.001). Controlling for these contextual features, we found that lean practices were more likely to participate in an incident command system for pandemic response (OR = 2.45, 95% CI: 1.24–4.82), engage in efforts to address clinician burnout (OR = 1.29, 95% CI: 1.03–1.60), and report stronger financial performance after the pandemic (OR = 2.57, 95% CI: 1.40–4.73). Additionally, after adjusting for all other lean processes, practice use of rapid improvement events (OR = 0.20, 95% CI: 0.06–0.70) and real-time data analysis tools (OR = 0.31, 95% CI: 0.11–0.90) was associated with lower reported impacts of workforce shortages on patient care. Conclusion Health systems continue to face challenges, making them vulnerable to major disruptions as experienced with the recent pandemic. Lean management may enhance organizational resilience and theability of primary care practices to respond to rapidly evolving environments.

This paper updates an implementation framework we first proposed 25 years ago for improving the quality of healthcare in the UK and USA, based on a multilevel approach to change involving the four core properties of: distributed leadership, a learning-oriented culture, team-based care and information technology applications. We now add a fifth, relational coordination. We assess subsequent developments to improve healthcare quality in both countries. While each has made some progress, they fall short of what is needed to address the evolving challenges of ageing populations, growing inequities in care and incorporating advances in cell, gene, informational and related technologies and therapies. We examine the macro policy contexts in the two countries that influenced past efforts to improve the quality of care, review the current state of quality initiatives, consider specific examples each country implemented and suggest what is needed in moving forward.

External incentives increasingly encourage hospitals to address health-related social needs, yet limited evidence exists about whether social needs interventions are associated with quality indicators like potentially preventable admissions. We analyze whether four hospital interventions—meal delivery, transportation to health services, mobile clinics, and community-oriented violence prevention programs—are associated with potentially preventable hospitalizations. Cross-sectional analysis of survey-based and claims-based data. In total, 813 hospitals from 14 states, representing 6,003,739 adult all-payer hospital admissions. This study merged 2017 Healthcare Cost Utilization Project State Inpatient Databases with 2017 American Hospital Association survey data. Generalized linear models for each of the four interventions were separately estimated to assess the association with potentially preventable hospitalizations, controlling for hospital and patient characteristics. Sensitivity analyses restricted regression modeling to adult Medicaid and Medicare beneficiaries. A minority (13

Policy Points This study highlights health care leaders' use of lean management practices to advance equity and scale initiatives supporting the delivery of high-quality care for all patients. As a next step in this work, there is a need to develop new measurement systems with clearly defined performance metrics that ensure accountability to equity standards. Standards can be reinforced by government agencies, professional associations, and accrediting bodies. Examples include building equity-specific metrics into Centers for Medicare and Medicaid Services' Medicare Advantage STAR ratings, American Medical Group Association and America's Physician Groups recognition programs, National Committee for Quality Assurance certification criteria for health plans, and Joint Commission accreditation for hospitals.ContextLean management is a sociotechnical approach to quality improvement that aims for consistency in work processes and outcomes. This can be leveraged to reduce inequities by ensuring delivery of high-quality care to meet the needs of patients with diverse backgrounds. Despite recent efforts in the field, there is limited study on how managers implement health equity and workforce diversity goals as strategies to improve patient care. Given the important role of leadership in fostering workplace culture, we examined leader activities and specifically their use of lean management practices to support equity initiatives in health care.MethodsWe conducted in-depth interviews with 67 leaders ranging from C-suite executives to frontline managers in five US hospital-health systems. Interview transcripts were analyzed and validated via parallel coding, yielding an interrater agreement of 92.6%. We identified cross-cutting themes on how leaders use lean methods to promote equity in care settings, and elicited insights regarding barriers, facilitators, and recommendations for continuous improvement.FindingsLeaders highlighted the lean daily management system (DMS) as a robust platform to introduce and scale systemwide equity initiatives. The DMS consists of standardized practices including tiered huddles, leader rounding, and problem-solving that enable employees to accomplish daily tasks in alignment with organizational priorities. Humble inquiry was also cited as an effective way to address patient safety issues while fostering cultural humility and learning. Leaders strongly recommend integrating equity into other strategic goals (quality, affordability, patient/employee experience) and stratifying data to inform key performance indicators. Recommendations to strengthen accountability include setting equity goals and building them into performance evaluations, clearly communicating cultural norms and expectations, and creating equity-focused data reporting systems as the next step or evolution in this work.ConclusionsHealth care leaders can use lean management to advance equity by reducing variation in care processes and improving measurement of outcomes across diverse populations.

Importance Many of the capabilities needed to deliver accessible, high-quality primary care have been defined, but little is known about how their implementation has changed in US practices over the course of the COVID-19 pandemic or about the factors associated with greater capabilities. Objective To describe US primary care practices' accessibility and capabilities and examine recent changes. Design, Setting, and Participants This was a retrospective cohort study across 2 surveys, in 2017 to 2018 and 2022 to 2023, among a national sample of primary care practice leaders in the US. Data were analyzed from January 2023 to September 2024. ExposuresDegree of integrated practice ownership and accountable care organization (ACO) participation. Main Outcomes and Measures Differences by practice ownership and ACO participation, and changes over time in access to care and care delivery capabilities. These were measured by composite scores of responses standardized to a scale of 0 to 100. Results This analysis included 710 practices, of which 234 were independently owned, 105 were physician group owned, and 321 were hospital/health system owned in 2017 to 2018, and 68 practices reported no ACO participation, 107 joined between surveys, and 486 otherwise participated in ACOs. Access to care (measured as extended weekday or weekend hours) was reported to decline from the first survey in 2017 to 2018 to the second in 2022 to 2023. Hospital/health system practices and ACO participants had higher rates of extended weekday hours than their comparators in 2022 to 2023. Average capability scores increased from 51 to 54 (increase of 4 points [95% CI, 1-6 points]). There was wide variation in scores within all ownership and ACO participant or nonparticipant groups. Capability scores were higher on average for more integrated practices (for physician groups compared to independent practices, 12 points [95% CI, 5-19 points] in 2017-2018 and 12 points [95% CI, 7-16 points] in 2022-2023) and for ACO participants compared to nonparticipants (13-point difference [6 to 20] in 2017-2018 and 12-point difference [6 to 18] in 2022-2023). Conclusions and Relevance In this cohort study, over the time period including the COVID-19 pandemic, primary care practices reported a decline in access to care, while average practice capabilities improved. Integrated practice ownership and ACO participation were both associated with better access and capability scores, suggesting that value-based payment and integrated care delivery support the development of higher-quality primary care. Variations across practices point to large opportunities for improvement overall and underscore the importance of incentives and structures as levers to improve primary care delivery.

Importance Federally qualified health centers (FQHCs) provide care to 30 million patients in the US and have shown better outcomes and processes than other practice types. Little is known about how the COVID-19 pandemic contributed to FQHC capabilities compared with other practices. Objective To compare postpandemic operational characteristics and capabilities of FQHCs with non-FQHC safety net practices and non-FQHC, non-safety net practices. Design, Setting, and Participants This nationally representative survey conducted from June 2022 to February 2023 with an oversampling of safety net practices in the US included practice leaders working in stratified random selection of practices based on FQHC status, Area Deprivation Index category, and ownership type per a health care network dataset. Exposures Practice type: FQHC vs non-FQHC safety net and non-FQHC practices. Main Outcomes and MeasuresPrimary care capabilities, including 2 measures of access and 11 composite measures. Results A total of 1245 practices (221 FQHC and 1024 non-FQHC) responded of 3498 practices sampled. FQHCs were more likely to be independently owned and have received COVID-19 funding. FQHCs and non-FQHC safety net practices were more likely to be in rural areas. FQHCs significantly outperformed non-FQHCs on several capabilities even after controlling for practice size and ownership, including behavioral health provision (mean score, 0.53; 95% CI, 0.51-0.56), culturally informed services (mean score, 0.55; 95% CI, 0.53-0.58), screening for social needs (mean score, 0.43; 95% CI, 0.39-0.47), social needs referrals (mean score, 0.53; 95% CI, 0.48-0.57), social needs referral follow-up (mean score, 0.31; 95% CI, 0.27-0.36), and shared decision-making and motivational interviewing training (mean score, 0.53; 95% CI, 0.51-0.56). No differences were found in behavioral and substance use screening, care processes for patients with complex and high levels of need, use of patient-reported outcome measures, decision aid use, or after-hours access. Across all practices, most of the examined capabilities showed room for improvement. Conclusions and Relevance The results of this survey study suggest that FQHCs outperformed non-FQHC practices on important care processes while serving a patient population with lower incomes who are medically underserved compared with patients in other practice types. Legislation to expand funding for the FQHC program should improve services for underserved populations and target current non-FQHC safety net practices to serve these populations. Increased support for these practices could improve primary care for rural populations.

Background: We examine pandemic-era quality of care changes associated with telemedicine use among adults with type 2 diabetes and/or hypertension across ten health systems. Methods: Patient-level encounter and laboratory data (n=1,963,563) were analyzed for pre-pandemic (March 13, 2019 to December 31, 2019) and pandemic (March 13, 2020 to December 31, 2020) periods. Generalized linear models with binomial distribution functions and log links estimated the association of telemedicine use with four outcomes: 1) hemoglobin A1c (HbA1c) testing, 2) HbA1c control (<8.0%), 3) blood pressure (BP) testing, and 4) BP control (<140 / 90 mmHg), controlling for patient characteristics, system fixed effects, and with propensity score weights. Results: In adjusted analyses, telemedicine use was associated with lower odds of HbA1c (aOR=0.74, p<0.05) and BP (aOR=0.40, p<0.01) testing for adults with type 2 diabetes, but not HbA1c or BP control. Among hypertension-only patients, telemedicine use was associated with lower odds of BP testing (aOR=0.10, p<0.001), but not BP control. Compared to pre-pandemic telemedicine use, pandemic period telemedicine use was associated with lower odds of HbA1c and BP monitoring. Discussion: Telemedicine use was associated with lower odds of HbA1c monitoring for adults with type 2 diabetes and lower odds of BP testing for adults with type 2 diabetes and/or hypertension. Conclusion: As telemedicine continues to be used for diabetes and hypertension care, remote monitoring, standing orders, and community pharmacy partnerships may be necessary supplements to telemedicine to assure high quality care, especially when in-person care options are limited.

Background and Objectives: To understand the relationship between Lean implementation in information technology (IT) departments and hospital performance, particularly with respect to operational and financial outcomes. Methods: Primary data were sourced from 1222 hospitals that responded to the National Survey of Lean (NSL)/Transformational Performance Improvement, which was fielded to 4500 general medical-surgical hospitals across the United States. Secondary sources included hospital performance data from the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare & Medicaid Services (CMS). We performed 2 sets of multivariable regressions using data gathered from US hospitals, linked to AHRQ and CMS performance outcomes. We examined 10 different outcomes measuring financial performance, quality of care, and patient experience, and their associations with Lean adoption within hospital IT departments. We then focused only on those hospitals that adopted Lean in IT to identify specific practices associated with performance. Results: Controlling for other factors, adoption of Lean IT management was associated with lower length of stay ( b = –0.098, P = .018) and inpatient expense per discharge ( b = –0.112, P = .090). Specifically, use of visual management tools (eg, A3 storyboards, status sheets) was associated with lower adjusted inpatient expense per discharge ( b = –0.176, P = .034) and higher earnings before interest, taxes, depreciation, and amortization margin ( b = 0.124, P = .042). Such tools were also associated with hospital participation in bundled payment programs (odds ratio = 2.326; P = .046; 95% confidence interval, 0.979-5.527) and percentage of net revenue paid on a shared risk basis ( b = 0.188, P = .031). Conclusions: Lean IT management was associated with positive financial performance, particularly with hospital participation in value-based payment. More detailed study is needed to understand other influential factors and types of work processes, activities, or mechanisms by which high-functioning IT can contribute to financial outcomes.

More than 700,000 physicians and advanced practice clinicians participate in Medicare ACOs, which is responsible for the cost and quality of care for more than 13 million beneficiaries. Nearly 40 percent of neurologists who treat Medicare patients are already in an ACO. The Centers for Medicare and Medicaid services is now implementing a strategy for value-based specialty care that promotes active ACO management of specialty services while some ACOs are starting to direct referrals to preferred specialist networks. Neurologists can benefit from engaging with ACOs through enhanced patient data, an emphasis on team-based care, care coordination support for their patients, and financial rewards for performance. Neurologists can help ACOs as the population ages, including by helping ensure appropriate use of expensive new therapies for neurologic conditions.

This study characterized adult primary care medical assistant (MA) staffing. National Survey of Healthcare Organizations and Systems (n = 1,252) data were analyzed to examine primary care practice characteristics associated with MA per primary care clinician (PCC) staffing ratios. In 2021, few practices (11.4%) had ratios of 2 or more MAs per PCCs. Compared with system-owned practices, independent (odds ratio [OR] = 1.76, P <0.05) and medical group-owned (OR = 2.09, P <0.05) practices were more likely to have ratios of 2 or more MAs per PCCs, as were practices with organizational cultures oriented to innovation (P <0.05). Most primary care practices do not have adequate MA staffing.

OBJECTIVES:The COVID-19 pandemic accelerated telemedicine use nationally, but differences across health systems are understudied. We examine telemedicine use for adults with diabetes and/or hypertension across 10 health systems and analyze practice and patient characteristics associated with greater use.STUDY DESIGN:Encounter-level data from the AMGA Optum Data Warehouse for March 13, 2020, to December 31, 2020, were analyzed, which included 3,016,761 clinical encounters from 764,521 adults with diabetes and/or hypertension attributed to 1 of 1207 practice sites with at least 50 system-attributed patients.METHODS:Linear spline regression estimated whether practice size and ownership were associated with telemedicine during the adoption (weeks 0-4), de-adoption (weeks 5-12), and maintenance (weeks 13-42) periods, controlling for patient socioeconomic and clinical characteristics.RESULTS:Telemedicine use peaked at 11% to 42% of weekly encounters after 4 weeks. In adjusted analyses, small practices had lower telemedicine use for adults with diabetes during the maintenance period compared with larger practices. Practice ownership was not associated with telemedicine use. Practices with higher proportions of Black patients continued to expand telemedicine use during the de-adoption and maintenance periods.CONCLUSIONS:Practice ownership was not associated with telemedicine use during first months of the pandemic. Small practices de-adopted telemedicine to a greater degree than medium and large practices. Technical support for small practices, irrespective of their ownership, could enable telemedicine use for adults with diabetes and/or hypertension.

Goal: This study investigated the association between Lean and performance outcomes in U.S. public hospitals. Public hospitals face substantial pressure to deliver high-quality care with limited resources. Lean-based management systems can provide these hospitals with alternative approaches to improve efficiency and effectiveness. Prior research shows that Lean can have positive impacts in hospitals ranging in ownership type, but more study is needed, specifically in publicly owned hospitals. Methods: We performed multivariable regressions using data from the 2017 National Survey of Lean/Transformational Performance Improvement. The data were linked to publicly available hospital performance data from the Agency for Healthcare Research and Quality and the Centers for Medicare & Medicaid Services. We examined 11 outcomes measuring financial performance, quality of care, and patient experience and their associations with Lean adoption. We also explored potential drivers of positive outcomes by examining Lean implementation in each hospital, measured as the number of units using Lean tools and practices; leader commitment to Lean principles; Lean training and education among physicians, nurses, and managers; and use of a daily management system among C-suite leaders and managers. Principal Findings: Lean adoption and implementation were associated with improved performance in U.S. public hospitals. Compared with hospitals that did not adopt Lean, those that did had significantly lower adjusted inpatient expenses per discharge and higher-than-average national scores on the appropriate use of medical imaging and timeliness of care. The study results also showed marginally significant improvements in patient experience and hospital earnings before interest, taxes, depreciation, and amortization margins. Focusing on these select outcomes, we found that drivers of such improvements involved the extent of Lean implementation, as reflected by leadership commitment, daily management, and training/education while controlling for the number of years using Lean. Practical Applications: Lean is a method of continuous improvement centered around a culture of providing high-value care for patients. Our findings provide insight into the potential benefits of Lean in U.S. public hospitals. Notably, they suggest that leader buy-in is key to success. When executives and managers support Lean initiatives and provide proper training for the workforce, improved financial and operational performance can result. This commitment, starting with upper management, may also play a broader role in the effort to reform healthcare while having a positive impact on patient care in U.S. public hospitals.

The complexity, pace, and volatility of present-day work demands more dynamic organizational management systems. More recent management systems, e.g., agile or design thinking, have not proven to be the “silver bullet” to improved dynamic capabilities in part due to the paradoxical nature of multi-faceted organizational outcomes (e.g., people v. profit, quality v. innovation). Thus, scholars seek to examine the underlying principles and theories of management approaches, regardless of origin or age. Our proposed presentation symposium combines historical and futuristic perspective to examine 21st century lean practices through the lenses of temporality, centrality of work teams, and problem solving. The use of lean management approaches shifted significantly since 2000, from primary use in manufacturing settings to achieve efficiency, to extensive use knowledge-based settings, including hospitals and R&D, to achieve improved efficiency, quality, and innovation. This symposium includes three presentations and a discussion from internationally renowned scholars that collectively highlight temporality, centrality of work teams, and problem solving as critical lenses through which to study and improve management systems. Building upon a pluralistic approach, this symposium will take a significant step in advancing knowledge and provoking new directions for future research on team-oriented management systems. Managing Through a Pandemic: A Daily Management System for COVID-19 Response and Recovery Author: Dorothy Hung; U. of California, Berkeley Author: Thomas Rundall; U. of California, Berkeley Author: Justin Lee; U. of California, Berkeley Author: Negeen Khandel; U. of California, Berkeley Author: Stephen M. Shortell; U. of California, Berkeley Factors for Kaizen Event Success in Hospitals Author: Kimberly Harry; Virginia Tech Author: Wiljeana Jackson Glover; Babson College The paradox of Lean Management and Innovation climates: Problem-Solving as a potential moderator Author: Tal Katz-Navon; Arison School of Business, Reichman U. (IDC), Israel Author: Eitan Naveh; Technion Israel Institute of Technology Author: Noa Ebenstein-Ziv; Technion – Israel Institute of Technology

Community health centers (CHCs) pivoted to using telehealth to deliver chronic care during the coronavirus COVID-19 pandemic. While care continuity can improve care quality and patients' experiences, it is unclear whether telehealth supported this relationship.We examine the association of care continuity with diabetes and hypertension care quality in CHCs before and during COVID-19 and the mediating effect of telehealth.This was a cohort study.Electronic health record data from 166 CHCs with n=20,792 patients with diabetes and/or hypertension with ≥2 encounters/year during 2019 and 2020.Multivariable logistic regression models estimated the association of care continuity (Modified Modified Continuity Index; MMCI) with telehealth use and care processes. Generalized linear regression models estimated the association of MMCI and intermediate outcomes. Formal mediation analyses assessed whether telehealth mediated the association of MMCI with A1c testing during 2020.MMCI [2019: odds ratio (OR)=1.98, marginal effect=0.69, z=165.50, P<0.001; 2020: OR=1.50, marginal effect=0.63, z=147.73, P<0.001] and telehealth use (2019: OR=1.50, marginal effect=0.85, z=122.87, P<0.001; 2020: OR=10.00, marginal effect=0.90, z=155.57, P<0.001) were associated with higher odds of A1c testing. MMCI was associated with lower systolic (β=-2.90, P<0.001) and diastolic blood pressure (β=-1.44, P<0.001) in 2020, and lower A1c values (2019: β=-0.57, P=0.007; 2020: β=-0.45, P=0.008) in both years. In 2020, telehealth use mediated 38.7% of the relationship between MMCI and A1c testing.Higher care continuity is associated with telehealth use and A1c testing, and lower A1c and blood pressure. Telehealth use mediates the association of care continuity and A1c testing. Care continuity may facilitate telehealth use and resilient performance on process measures.

BACKGROUND AND OBJECTIVES:Despite the rapid spread of Lean management in health care, few organizations have achieved measurable overall performance improvements with Lean. What differentiates these organizations from those that struggle with realizing the potential benefits of Lean management is unclear. In this qualitative study we explore measuring the impact of Lean and the recommended practices for achieving measurable performance improvements with Lean in health care organizations.METHODS:Informed by preliminary quantitative results from analyses of high- and low-performing Lean hospitals, we conducted 17 semi-structured interviews with Lean health care experts on the Lean principles and practices associated with better performance. We conducted qualitative content analyses of the interview transcripts based on grounded theory and linking to core principles and practices of the Lean management system.RESULTS:The qualitative data revealed 3 categories of metrics for measuring the impact of Lean: currently used institutional measures, measures tailored to Lean initiatives, and population-level measures. Leadership engagement/commitment and clear organizational focus/prioritization/alignment had the highest weighted averages of success factors. The lack of these 2 factors had the highest weighted averages of biggest barriers for achieving measurable performance improvements with Lean implementation.CONCLUSIONS:Leadership engagement and organizational focus can facilitate achieving the organization's performance improvement goals, whereas their absence can considerably hinder performance improvement efforts. Many different approaches have been used to quantify the impact of Lean, but currently used institutional performance measures are preferred by the majority of Lean experts.

Objective To examine the effect of enrollee switching from a broad-network accountable care organization (ACO) health maintenance organization (HMO) to a "high performance" ACO-HMO with a selective narrow network and comprehensive patient navigation system on access, utilization, expenditures, and enrollee experiences. Data Sources Secondary administrative data were obtained for 2016-2020, and primary interview and survey data in 2021. Study Design Fixed-effects instrumental variable analyses of administrative data and regression analyses of survey data. Outcomes included access, utilization, expenditures, and enrollee experience. Background information was gathered via interviews. Data Collection/Extraction Methods We obtained medical expenditure/enrollment and access data on continuously enrolled members in a broad-network ACO-HMO (n = 24,555), a subset of those who switched to a high-performance ACO-HMO in 2018 (n = 7664); interviews of organizational leaders (n = 13); and an enrollee survey (n = 512). Principal Findings Health care effectiveness data and information Set (HEDIS) access measures were not different across plans. However, annual utilization dropped by 15.5 percentage points (95% CI: 18.1, 12.9) more in the high-performance ACO-HMO, with relative annual expenditures declining by $1251 (95% CI: $1461, $1042) per person per year. High-performance ACO-HMO enrollees were 10.1 percentage points (95% CI 0.001, 0.201) more likely to access primary care usually or always as soon as needed and 11.2 percentage points (95% CI 0.007, 0.217) more likely to access specialty care usually or always as soon as needed. Plan satisfaction was 7.1 percentage points (95% CI: -0.001, 0.138) higher in the high-performance ACO-HMO. Interviewees noted the comprehensive patient navigation system was designed to ensure patients remained in the narrow network to receive care. Conclusions ACO and HMO contracts with selective narrow networks supported by comprehensive patient navigation can reduce expenditures and improve specialty access and patient satisfaction compared to broad-network plans that lack these features. Payers should consider implementing narrow networks with comprehensive support systems.