Expand Without Dilution

Begin With What Care Reveals

Stage Six begins after the first operating model has had enough time to show how the system works in practice.

The clinical arcs will reveal where the model is strong, where execution can improve, which services are missing, which protocols require refinement, and which resources could be organized more effectively.

Some needs will be local. Others will appear repeatedly across patients, practitioners, and care settings. Those recurring needs identify the next layer of the system.

Stage Six uses that evidence to refine the first build and begin developing the shared support that local care cannot efficiently create alone.

Refine the Working Model

The first responsibility of Stage Six is to improve the system already in operation.

Refinement may include:

• clarifying clinical protocols;
• improving communication through the primary care hub;
• adjusting the sequence or availability of services;
• strengthening referral and escalation pathways;
• improving access through clinic, home, telehealth, workplace, or community settings;
• refining outcome measures and review intervals;
• improving member education and participation;
• correcting administrative or financial friction;
• and strengthening the transition toward independent self-management.

The purpose is to make the operating model more capable of completing the arc of care while preserving the principles that gave the model its direction.

Expand What Care Can Reach

Refinement may show that patients and care teams need access to additional services, expertise, or resources.

These may include:

• additional clinical or therapeutic disciplines;
• specialty consultation;
• pharmacy and medication access;
• laboratory and diagnostic services;
• rehabilitation and home-based support;
• mental health and behavioral resources;
• nutrition and health education;
• community-based programs;
• and technologies that improve communication, access, or continuity.

Services are added because the care demonstrates a recurring need for them. Expansion remains accountable to the arc rather than becoming an accumulation of offerings.

From a Federated Backbone to an Outer Ring

The broader PrimaryCare.Solutions roadmap describes a federated backbone: shared capacity that no single clinic or local cooperative could reasonably build alone.

That description remains accurate. Technology, training, purchasing, credentialing, data systems, legal support, shared risk, and collective representation can provide the structural strength that allows multiple local organizations to operate more effectively.

But the position of that structure within the model matters.

In many systems, the central organization becomes the center of gravity. Resources, authority, and standardization move inward, while care delivery becomes an outer function expected to conform to the institution.

PrimaryCare.Solutions begins from the opposite direction.

The patient and care team relationship remains at the center. The primary care hub holds the arc around that relationship. The local cooperative organizes the people and resources required to deliver care. Shared federated capacity forms an outer ring around this work.

The distinction is more than visual.

The outer ring does not begin by deciding what local care should use. It listens for recurring needs revealed through care, identifies where shared capacity would help, and translates available resources into practical support for local teams.

Need moves outward from care. Support returns inward from the federation.

This keeps the larger system accountable to its core competency. The purpose of the federation is not to become the largest or most powerful part of the model. Its purpose is to make excellent local care easier to deliver, sustain, and reproduce.

Build the Ring From Care Outward

As the working model matures, some needs will extend beyond what one local clinic or cooperative can efficiently provide.

When the same need appears repeatedly across patients, practitioners, or care settings, the federation can determine whether that resource should be developed, purchased, maintained, or represented collectively.

Shared functions may include:

• technology and data infrastructure;
• outcome measurement and reporting;
• clinical protocols and implementation resources;
• education and practitioner training;
• quality review and credentialing;
• pharmacy, laboratory, and supply relationships;
• specialty and telehealth resources;
• legal, regulatory, and administrative support;
• purchasing and contracting;
• financial safeguards and shared risk capacity;
• cooperative development assistance;
• research and evaluation;
• and advocacy and collective representation.

Not every function must be shared, and not every local cooperative will require the same resources. A function belongs in the outer ring when organizing it collectively makes local care more capable, accessible, reliable, or affordable.

Keep Care at the Center

The core competency of the system remains care.

The primary relationship is between the patient and the care team. The hub holds the objective and coordinates the arc. The local cooperative organizes care around the needs and resources of its own community.

The outer ring exists to make that work easier and stronger.

Information about what care requires moves outward from the local system. Resources, training, infrastructure, and support then move back toward the places where care is delivered.

What Remains Local

Local cooperatives must retain the ability to respond to their own populations, relationships, practitioners, geography, and available resources.

Local responsibility may include:

• the patient and care team relationship;
• clinical judgment;
• the composition of the local care team;
• the organization of access;
• relationships with community resources;
• member participation;
• and decisions that depend on local conditions.

What Can Be Shared

Shared capacity should be developed where it strengthens local care without displacing local responsibility.

The federated support ring can:

• reduce duplication;
• give small organizations access to greater expertise;
• improve purchasing power;
• support consistent clinical and operating standards;
• make training and quality improvement transferable;
• provide infrastructure that would be too costly for one clinic to maintain;
• and represent shared interests with a stronger collective voice.

Prepare What Can Travel

The work in Minnesota should also produce resources that another community can understand and adapt.

This may include:

• tested clinical arc templates;
• outcome and decision frameworks;
• operating protocols;
• care team and hub standards;
• financial models;
• governance structures;
• implementation guidance;
• training resources;
• and a record of what changed as the first model was refined.

The goal is not to produce a fixed Minnesota model for other communities to copy. It is to make the knowledge gained through the first build available so that others can begin with a stronger foundation.

The Required Result

A refined operating model supported by a clearly defined federated outer ring.

The result will identify:

• what the first build has learned from delivering care;
• which clinical and operating elements have been improved;
• which additional services or resources are needed;
• which responsibilities should remain local;
• which functions are better organized and shared;
• how shared support remains accountable to local care;
• and which parts of the model are ready to be adapted by another community.

The Readiness Standard

Stage Six has succeeded when the first model is stronger because of what it has learned, shared resources are doing useful work for the care team, and the larger structure remains organized around the needs of care rather than its own growth.

The federated support ring must strengthen local capacity, preserve clinical coherence, and leave local cooperatives responsible to the communities they serve.

The model is ready to support another build when its operating knowledge can travel, its shared resources can serve more than one local organization, and a new community can adapt the framework without weakening the care at its center.