New for 2016, AIMM developed an innovative framework for health care organizations participating in the AIMM Collaborative. Organizations assemble as a team and work throughout the year to present their actionable results and outcomes in the context of their “performance story.” The development of the performance story and progress being made is discussed and shared with the team’s AIMM learning coach on a monthly basis.  A team performance story starts out as a template document that describes seven critical elements, which illustrate a team’s organizational structure, delivery system composition and clinical outcomes. The specific elements are:

  1. Overview of the organization.
  2. Team’s bold aim statement and vision to scale-up.
  3. A description of the integrated care team and delivery system.
  4. Clinical results from your selected population of patients.
  5. Impact of the delivery system to identify and resolve Medication Related Problems.
  6. Efforts to improve the delivery system using a quality improvement process.
  7. Use of effective leadership style to obtain necessary resources.

Using these seven elements as a design framework, teams develop their performance stories based on the goals and needs of their own organizations.  The goals and needs are unique to each team and are flexible and designed to evolve over time.

With a performance story, organization’s participating in AIMM are now accountable on a monthly basis to document and show progress in practice transformation that is related to their own organization’s strategic vision.  One AIMM team remarks: “The development of our Performance Story has been a valuable exercise for our organization.”

Below are a few examples of AIMM teams generating powerful results through their performance stories:

North Country is a Federally Qualified Health Center (FQHC) located in Flagstaff, AZ. They have a presence in 14 communities and serve 50,000 patients. One of North Country’s biggest area of focus is their diabetic patient population. As a part of their AIMM experience, North County is tracking the impact of their Diabetes Education Classes. These classes are designed to help patients who are struggling to manage their diabetes, and provide onsite and online resources. The classes also serve to identify patients that need one-on-one counseling with clinical pharmacists or follow up services for their diabetes management.

Over a six-month period, 70 patients with diabetes not at goal attended these classes (North Country defined not at goal as an A1C>7). During the time, 31 patients or 44% reached their A1C goal.

Valley Wide Health is a FQHC located in Alamosa, CO. They serve a population of 34,319. The primary patient population of focus is their anticoagulation patients, which is approximately 92 patients. These patients are served through the clinical pharmacy administered anticoagulation Clinic. Through their AIMM experience, Valley Wide Health tracked 90 patients between May 2016 and August 2016.  By the end of August 2016, 75 patients or 83% had their INR within therapeutic range.

Essentia Health is an integrated health system serving patients in Minnesota, Wisconsin, North Dakota, and Idaho. Essentia Health has over 13,900 employees, including nearly 1,800 physicians and advanced practitioners that serve roughly 534,000 patients. Essentia estimates that roughly 22% or 120,000 patients are considered high-risk, of which, 4,200 are receiving comprehensive medication management (CMM) services.

Essentia Health joined AIMM in 2012 with an initial goal of getting the A1c levels of 90 patients with diabetes under 9. Essentia also set a goal of having clinical pharmacy services accessible at all of its clinics to collaborate with care teams and patients to improve outcomes for patients with diabetes, asthma, depression, hypertension, vascular disease and/or chronic pain by 2017.

In 2012, they successfully helped 75% of their initial population of focus (90 patients with diabetes not at goal, A1C>9) get their A1c levels under 9 within 6 months. Essentia continued to expand their diabetes program. In 2015 Essentia tracked 121 diabetic patients. They were able to bring 65% of these patient to goal (A1C<8) in 6 months.

The success of their patient population with diabetes, as well as their successful integration into Essentia’s primary care network, allowed them to successfully achieve AIMM’s Gold I Recognition process, where one’s performance story demonstrates a significant leap into scaling and spreading of services. Essentia’s clinical pharmacy team used the AIMM Gold I Recognition presentation to promote their services internally. By celebrating their success and leveraging their physician champions, Essentia has been able to expand their program by 4 full-time employees and have spread into new clinical programs such as Opioid Tapering in pain management patients and reducing readmissions for transition of care patients.


Paul Scanlon
AIMM Management Team
Advanced Team Learning Coach