Driving Healthier Outcomes Through Comprehensive, Team-Based Care: Q&A With Marisa Rogers, MD, MPH

Am J Manag Care. 2025;31(Spec. No. 10):SP724-SP726. https://doi.org/10.37765/ajmc.2025.89799

In 2025, each issue of Population Health, Equity & Outcomes (PHEO) features a profile of a health system leader transforming care in their area of expertise. This issue spotlights a conversation with Marisa Rogers, MD, MPH, chief medical officer at Oak Street Health. This interview has been edited for
length and clarity.

PHEO: Please tell me about your typical workday as the chief medical officer for Oak Street Health.

ROGERS: It feels like there’s not a day that’s pretty typical; I think there’s a lot of variability to what I do. For example, I continue to see patients in one of our health centers for half a day a week, and so today I saw patients with a pretty standard panel. One of the patients I saw was someone who was recently out of the hospital. That’s really important for us to make sure we’re seeing patients within 7 days of discharge, to make sure that we’re following up on any loose ends or any follow-up testing, making sure they’re on the right track for their care to decrease the likelihood of readmission. So, I did see patients this morning, but a typical day when I’m not seeing patients often involves meetings. I have a wonderful group of folks who work with me to execute the mission at Oak Street. My leadership team includes executive medical directors as well as leaders from our provider education and wellness team, as well as our provider recruitment team, so I am often meeting with members of that team to strategize around hiring. How do we engage our providers? How do we make sure we’re supporting their needs? We review a variety of data points around our providers that help us keep the pulse on how our providers are doing. How are we assessing feedback and implementing feedback from our providers to continue to support them in our mission?

I also work very closely with our operational leaders. I met today with my COO [chief operating officer] Anand [Nagarajan]. We partner together as leaders of our field teams: myself, from the primary care providers, and our behavioral health specialists, and then he has the operational leaders and some of the teams that support clinical care. We meet to talk about strategic priorities, around execution on the operational levers in the field, and how we can be successful. We troubleshoot problems and think strategically around how to continue to elevate performance around some of our key outcomes, which are really around growth, medication cost management, as well as clinical care measures around screening and diagnosing our patients, so we’re successful in our model.

I also travel, so this week I was in Chicago, Illinois, visiting 2 centers. It’s a great opportunity to engage our teams, see how things are going on the field, really talk to providers, and get a sense of what’s going well and what’s not as well. So, the week has been pretty varied.

PHEO: How does Oak Street Health’s integrated care approach help support patients with chronic conditions?

ROGERS: Great question. Our model is about a few things. It is about comprehensive team-based care to drive outcomes differentially for our patients who need it. I always tell people we cannot be successful just on our own as clinicians; we really need deep partnerships with other team members. Those include behavioral health specialists who are in every center. We are pretty comprehensive around screening for chronic disease issues, behavioral health issues, and social factors, and our goal is to address them and help them to not lead to complications and mitigate someone’s health, so we need our behavioral health specialists to help us be part of the care plan for discussing behavioral health challenges with patients. We have telehealth psychiatric NPs [nurse practitioners] who can help with a complex diagnosis or medication management. Our social workers and our community health workers help us navigate some of those social determinants of health by helping link people to community resources, whether that’s housing or food insecurity, and we have folks in the center who can help with insurance challenges. Perhaps someone’s insurance is not the best plan for them, and [burdening] them with high co-pays or not being able to afford certain medications—we have folks in the center who can help assess that patient and support them as they navigate insurance options and benefits.

It’s really a holistic picture of how we are screening patients not just for medical issues, but also social and behavioral issues. We know that with our patients and their complexity, if we don’t address the social influences of health, we’re not going to be able to make headway on the things that lead to them going to the hospital, like diabetes, hypertension, heart failure, and COPD [chronic obstructive pulmonary disease]. It has to be a comprehensive picture to address all the factors that lead to optimal health.

PHEO: In addition, Oak Street Health has been a leader in addressing the loneliness crisis. Please talk a bit about how community connection fits into Oak Street’s approach to care.

ROGERS: Yes, it’s really interesting. I think we are increasingly finding evidence around the impact of social isolation, particularly on seniors. I think we’ve learned a lot, unfortunately, through the COVID-19 epidemic, where people were unfortunately cooped up in their houses and didn’t have a lot of social engagement, and the sort of impact that that had on chronic disease burden, I think we will probably be living with for decades moving forward, but
we definitely know that loneliness is really an unrecognized health risk for older adults, contributing to lots of comorbidities like heart disease and
risk of stroke.^1,2

Connection and engagement are so important. Most of our centers have community rooms. It allows people to come whenever they want, not just when they have a medical appointment, and participate in classes and engage with other seniors. There are computers there that they can use if they don’t have access at home, and so it’s a way for our patients to have an opportunity to engage physically—it could be a yoga class or a stretching class—but also engage socially with their peers, because those are really important and can help with chronic disease management.

There’s also an emerging body of literature around the impact of social isolation on dementia.³ We know our patients are often high risk for dementia because of age, but also other comorbidities such as diabetes and hypertension. Making sure that people are active and engaged, making sure that they have access to high-quality vision so they can see and hearing aids and things of that nature really help with chronic disease management as well as prevention of dementia, so it’s critically integral to patients and to part of the work that we’re doing.

PHEO: How do primary care and specialty care complement one another in Oak Street’s health model?

ROGERS: A lot of our patients have a lot of medical complexity, and most of our patients have more than 2 chronic conditions. First, we want to provide robust primary care so that we are using all of our clinicians to the top of their license. We have robust programs for hypertension management [and other] disease management. We have our essential telehealth program that helps us escalate guideline-directed medical therapy for certain cohorts of patients with heart failure. We really try to provide evidence-based chronic disease management within the walls of primary care. Now, we certainly know that there’s an opportunity to engage specialists for some of our more complex patients, and we do that in a couple of different ways. One of the ways is that we have an e-consult tool built into our electronic health record. That tool enables us to send an electronic consult directly to a specialist. We can upload documents from the chart, ask the clinical question, and we typically get an answer back within a few hours, and so we’re able to incorporate that into the patient’s care plan quickly and help accelerate those insights.

I think that is really nice because it’s like bringing specialty-level impact into primary care. And so many times, we may not even need to send to an external specialist because we’re able to do that, but certainly we know there are many times where we do need external specialists, and then what we do in that case is we cultivate a preferred specialist network in all of our regions so that we’re finding specialists who are providing high-quality, cost-effective care and also a good patient experience to our patients. And so, we certainly tap into those networks locally, and we continue to refine those lists as we get feedback from patients and clinicians around those engagements.

PHEO: Finally, can you tell me about any upcoming initiatives your team is working on that you’re passionate about?

ROGERS: One of the most exciting things we’ve been working on is a transition through our electronic health record. We have used some tools that we have had since our inception, over the past several years, but I think as we’ve grown in scale, we’ve seen a need for a tool that better meets our needs, and so we are in the process of transitioning to Epic for a few reasons; one is because of our national scope. We’re in 27 states and have more than 230 centers, so we really need to be able to access patient information broadly across the US. Given Epic’s scale and scope, that’ll enable us to have access to specialty care, laboratory results, test results, and hospital records much more easily, so we’re excited about that.

It also has tools that enable some workflow efficiencies that I think will be really helpful for our teams, to make work more efficient and easier for our center teams. And then lastly, I would say it has great tools to engage patients, whether that be through apps or other text information that you can send patients. The ability to have bidirectional, asynchronous communication with patients, we think this will help enable efficiencies with giving things like test results, doing triage, really meeting patients’ needs around when they call us and being more responsive. We’re excited as we transition to a new [electronic health record] to improve our operations and our ability to care effectively for our patients.

PHEO: That was the end of my questions. Was there anything else that you wanted to add?

ROGERS: The one thing I will say is that health equity is really important to us, and I wouldn’t want to not mention something related to health equity, given the focus of your work and your publication. We really strive to make sure that all of our interventions are hitting all of the diverse populations that we care for. We have patients from a wide variety of backgrounds, and we really work to make sure that we’re providing patient-centered care and that our interventions work for all our populations and patients. That’s an active approach that we engage in, and it helps us learn more about how to make sure that we’re being successful across all different types of geographies, genders, races, ethnicities, etc.

REFERENCES

1. Valtorta NK, Kanaan M, Gilbody S, Ronzi S, Hanratty B. Loneliness and social isolation as risk factors for coronary heart disease and stroke: systematic review and meta-analysis of longitudinal observational studies. Heart. 2016;102(13):1009-1016. doi:10.1136/heartjnl-2015-308790
2. Golaszewski NM, LaCroix AZ, Godino JG, et al. Evaluation of social isolation, loneliness, and cardiovascular disease among older women in the US. JAMA Netw Open. 2022;5(2):e2146461. doi:10.1001/jamanetworkopen.2021.46461
3. Ren Y, Savadlou A, Park S, Siska P, Epp JR, Sargin D. The impact of loneliness and social isolation on the development of cognitive decline and Alzheimer’s disease. Front Neuroendocrinol. 2023;69:101061. doi:10.1016/j.yfrne.2023.101061