Large Scale Initiatives
We design and lead large-scale practice transformation initiatives.

Design & deliver high-value care to improve quality and lower cost by reducing readmissions and transforming care for multi-visit patients
Data Informed ~ Clinically Credible ~ Operationally Feasible ~ Locally Adaptable ~ Measurably Effective
We design and lead large-scale practice transformation initiatives.
We advise agencies, associations, payers, providers, and innovators.
We move teams into action and catalyze change to achieve results.
We inform and inspire change through sharing insights from leading care transformation.
Award
National award for Innovation and Excellence in enhancing the lives of America's seniors through clinical leadership, policy vision, and by superior example.
Formerly the Dr. Martin L. Block Award
RISE NationalPublication
Multi-Visit Patients are patients whose needs are not well met by the current care delivery system. The MVP Model is designed to identify and address the underlying issues that result in and perpetuate a cycle of recurrent utilization. This is a transformative systems-based population management approach that has resulted in meaningful impact on patient lives, care delivery through equitable, high value care.
Transforming Care Delivery and Outcomes for Multivisit Patients · July 2023
Read the case studyPublication
Harris Health Systems, shares their successful experience with implementing the MVP program to transform care for multivisit patients.
A New Way To Support Frequent Emergency Department Visitors · July 2022
Read the articleBrief
Every hospital, every ED, every ACO, and every health plan has multi-visit patients (MVPs). Few have an effective strategy. The MVP Method is a transformative model of care because it is designed to slow the cycle of utilization for this population - delivering quality, equity + value.
Building An Effective Care Pathway for Multi-Visit Patients: The MVP Method · April 2023
Read the briefGuide
We wrote the book on reducing Medicaid readmissions for AHRQ.
Read the guidePodcast
Listen to the Race to Value Podcast to learn why every readmission reduction portfolio of strategies must include a multi-visit patient care pathway.
Ep 161 – The "High Utilizers": Transforming Care for Multi-Visit Patients (MVPs), with Dr. Amy Boutwell
ListenPodcast
On this podcast, Dr. Amy Boutwell, an expert in high-utilizer care, discusses her MVP Method, used successfully in a recent Vizient performance improvement collaborative.
Managing high utilizers · March 2021
Listen1,000+ teams over 15 years
CHART: 27 Massachusetts hospitals — 100% met their transformation goals
MAX: 87 teams in 68 New York hospitals
18% fewer readmissions in year one (MAX)
“Amy's passion and understanding of care transitions allowed Cityblock to build a sustainable inpatient and community care transition process.”
“Dr. Boutwell's approach shifts the paradigm and engages providers in critical thinking and problem solving that creates meaningful change.”
“What you got this team to do in 9 months would have easily otherwise taken 4 years - and 2 people would have quit!”