What does it take to scale a pilot program into a systemwide population health success?
For leaders at Providence, Trinity Health, Novant Health and Ballad Health, the answer lies in the methodical — and often complex — work of redesigning care around patients: not simply treating illness, but transforming health outcomes at scale.
From managing chronic disease to supporting prenatal care and preventing diabetes, these health systems are pushing beyond traditional boundaries of care delivery. Their initiatives — once isolated pilots — now span states and serve thousands, driven by strategic partnerships, technology infrastructure and unwavering commitment to value-based care.
In this feature, executives share how they turned small-scale population health efforts into systemwide engines for equity, access and sustainability and what it takes to keep growing.
Executives from four leading health systems told Becker’s how they transformed small-scale population health efforts into systemwide engines for equity, access and sustainability as well as what it takes to sustain that growth.
Editor’s note: Responses were lightly edited for length and clarity.
Question: What’s one population health initiative that went from pilot to systemwide implementation — and what made it scalable?
Daniel Roth, MD., Chief Clinical and Community Division Operations Officer, Trinity Health (Livonia, Mich.): In a cooperative agreement with the CDC, Trinity Health implemented the National Diabetes Prevention Program, an initiative designed to prevent or delay the onset of Type 2 diabetes. The 12-month, evidence-based lifestyle change program is intended to reduce the risk through adoption of healthy eating habits, increased physical activity and stress reduction. Since piloting the program in five locations in 2017, Trinity Health scaled the initiative to locations across 13 states.
Scaling the program throughout the system was the result of a variety of efforts. We tapped into our EHR system to screen, test and refer qualified individuals to a CDC-recognized delivery organization specifically using point of care referrals and care management models (patient registries). In addition, we standardized data collection, screening, billing and documentation that allowed for automation, quality analysis and facilitated collaboration.
As part of the work to expand, we added skilled community health workers in each region to support screening participants for health-related social needs at regular intervals and remove barriers to participation. Partnerships with community-based organizations in regions where there were gaps in delivery allowed expansion of the Trinity Health delivery hub. Additionally, earning increased revenue through Medicare expanded coverage, payer engagement and best practice advisory flags embedded into our billing systems create improved opportunities for sustainability nationwide.
Results:
From September 2017 to June 2025, Trinity Health and its delivery network has enrolled 7,551 participants into the lifestyle change program.
From June 2023 to June 2025, Trinity Health and its delivery network sent 202,129 outreach messages to qualified patients, screened 929 patients for health-related social needs and 49 of those are receiving services from a community health worker.
Susan Huang, MD, Chief Physician Executive, Providence (Renton, Wash.): The initial pilot of Providence’s Health Connect Partners — its Medicare Shared Savings Program ACO — included a broad set of participants from the Puget Sound region in Washington state. For three years, HCP gained experience in the mechanics of the program, including data processing.
Over the past decade, HCP has increased its sophistication and capabilities, expanding to service areas across five of our seven states and refining its composition.
Over time, HCP took on higher levels of risk, reflecting the organization’s confidence to consistently deliver high-quality, cost-effective care across diverse markets. Scalability was made possible through iterative learning, strong data infrastructure and a steadfast commitment to improving patient outcomes while reducing unnecessary spending.
The Transitional Care Management dashboard is one recent HCP population health initiative that successfully scaled from pilot to systemwide adoption. Developed in 2024 by Providence’s analytics center of excellence to support post-discharge patient tracking, the dashboard enables monitoring of encounters within two days and follow-up visits within 14 days.
This dashboard was propelled by strong executive sponsorship and strategic engagement with market leadership, which helped shape business requirements and drive alignment with the system’s focus on reducing 30-day all-cause readmissions. Operational teams, informed by leadership collaboration, refined EMR workflows to better reflect outreach efforts occurring within the first 48 hours after discharge. A systemwide TCM workgroup continues to guide optimization, identifying and addressing data gaps to enhance dashboard performance. This layered engagement — spanning executives, operations, clinical and analytics — ensured the initiative’s scalability and long-term success.
Anthony Keck, Executive Vice President, System Innovation and Chief Population Health Officer, Ballad Health (Johnson City, Tenn.): One of Ballad Health’s four north star goals is to become a national model for rural health. In the Appalachian Highlands this demands an emphasis on reducing generational poverty in partnership with an accountable care community representing over 400 community-based organizations of schools, government, business, faith-based organizations, health providers and others. Given the link between income, education, health and well-being, we determined that ensuring every child in the region graduates career or college-ready should be the primary focus.
As a health system, we’ve launched many programs to do our part. This includes Strong Starts, a community health navigation program for pregnant and parenting women, beginning with prenatal outreach and continuing until each child enters kindergarten. Our objective is for every child entering kindergarten to be ready to learn. Enrolled caregivers are paired with a community health navigator who will connect them with resources, provide social support, and work with them to create goals for themselves and their families.
The program is open to all pregnant and parenting mothers. By performing most of the deliveries in the region (about 6,000 annually) we can reach the entire community — not just patients affiliated with our employed OB/GYNs. Strong relationships with private providers and a closed-looped referral system, known as Unite Us, are integrated with Epic and allow us to work with thousands of families and hundreds of caregivers and social service providers.
Alice Pope, Executive Vice President, CFO, Novant Health (Winston-Salem, N.C.): Novant Health’s population health services organization is pivotal in transforming our value-based care capabilities into best-in-class solutions that can be scaled across the system. For example, our chronic care management services launched three years ago as a pilot and are now being scaled across clinics and acute care facilities systemwide. In acute care settings, a dedicated, centralized team aids with patients discharged with at least two chronic conditions. In clinics, CCM partners RN care managers with primary care physicians and APPs. RN care managers work alongside primary care physicians to care for these patients by supporting them with chronic conditions, assessing social drivers of health needs, developing care plans and completing annual wellness visits.
Regardless of the setting, our goal is to improve outcomes, reduce care gaps, improve quality metrics and reduce readmissions. The team has helped more than 1,000 patients with overwhelming positive responses, including helping patients lower blood pressure and A1C, manage a healthy weight and quit smoking. By providing critical education and support, we are empowering patients to understand and manage their chronic conditions, ultimately improving their overall wellbeing. Once the program is embedded in all acute care facilities, we anticipate expanding CCM to include additional diagnoses so we may reach more patients. Eventually we hope to offer this service to our clinically integrated network partners and beyond.
Q: What are the next steps to grow this initiative in the coming years?
Daniel Roth, MD, Chief Clinical and Community Division Operations Officer, Trinity Health (Livonia, Mich.): In the coming years, we will be focusing our growth efforts on building a sustainable model through stakeholder collaboration, including healthcare providers, community organizations, policymakers and patients. We will also be looking to increase revenue capabilities to cover the cost of the intervention and wrap around social care through Medicare expansion models and increased payer engagement. We will also be looking to build capacity and workforce related to this work, and grow modalities of delivery options to increase reach and have a sustained impact.
Susan Huang, MD, Chief Physician Executive, Providence (Renton, Wash.): We are committed to advancing our work in HCP by continuously evaluating our current models and identifying opportunities to improve, both as an ACO and as a healthcare system dedicated to value-based care. Innovation remains at the heart of our strategy. We are leveraging advanced analytics and modeling tools to assess financial performance under various configurations, helping us make data-informed decisions about future participation and risk strategies.
These efforts are complemented by our ongoing work to reduce costs and enhance patient care — made possible by the dedication of our caregivers and our focus on continuous improvement. We support CMS’s efforts to refine benchmark methodologies and to develop new CMMI models that meaningfully incentivize participation in value-based care. These policy advancements are critical to ensuring the long-term sustainability and impact of ACOs. Ultimately, our growth will be guided by our commitment to improve health outcomes, advance health equity and deliver value to the communities we serve.
Anthony Keck, Executive Vice President, System Innovation and Chief Population Health Officer, Ballad Health (Johnson City, Tenn.): We currently have 7,431 caregivers and 9,358 children active in the program and we are growing enrollment by about 4,000 a year. To this point, we’ve been funding it entirely on our own — about $2.2 million annually for program staff and support. To grow, we continue working with the Departments of Health and Medicaid in Tennessee and Virginia to obtain community health worker reimbursement. We are also implementing new automation and AI to allow for better identification of and outreach to families in need, allowing navigators to spend time working with families who need the help — and not making dead-end phone calls, for example.
