Building effective community-based IBD care: Key challenges and opportunities

Most patients with inflammatory bowel disease (IBD) in the United States receive care in community practices that vary widely in size, staffing, and resources. Yet IBD management is becoming increasingly complex, driven by rising prevalence, an aging population, and rapidly evolving therapies.

In a Gastroenterology commentary, Erica R. Cohen, MD, of Capital Digestive Care in Chevy Chase, Maryland, and Timothy Ritter, MD, of the GI Alliance in Southlake, Texas, introduced the IBD Community Care Initiative, an AGA-sponsored effort to better understand the realities of IBD management in community settings.

“I fear practices will lose their relevance if they do not start building systems and processes for cognitive care pathways like IBD,” Cohen, who co-chaired the initiative with Ritter, told GI & Hepatology News. “All of this risks negatively impacting patient care. To me, all of this is very urgent.”

In May 2024, Cohen and Ritter worked with the IBD Community Care Initiative Working Group to survey 102 clinicians from private practices with at least 10 providers and a weekly IBD caseload of 10 or more patients. The survey focused on how integrated care models can be implemented outside academic centers. Respondents highlighted four challenges familiar to many gastroenterologists:

• Ensuring fair compensation for complex, primarily cognitive work

• Preventing delays in care and care coordination and access

• Lack of an identified care team

• Limited experience implementing new care models in private practice

Despite these barriers, the working group identified several integrated care models already operating successfully in community settings.

Remote monitoring
Third-party remote monitoring platforms allow practices to track symptoms between visits, receive alerts when deterioration occurs, and intervene early. These models typically rely on risk-based payer contracts or remote patient monitoring reimbursement codes but require minimal upfront investment, making them appealing to small and mid-sized practices. They also promote proactive rather than reactive care and have demonstrated reductions in hospital utilization.

Advanced practice provider–led programs
Another option is the development of APP-led programs in which nurse practitioners or physician assistants coordinate triage, patient education, and routine follow-up using structured protocols. Such programs expand patient access and distribute workload more evenly, allowing physicians to focus on the most complex decisions. Many practices adopting this model report improved satisfaction among both clinicians and patients.

Hospital partnerships
Some community groups have partnered with local hospitals through joint ventures to gain access to nutritionists, social workers, patient navigators, and other services that are difficult for private practices to support independently. By sharing resources and aligning incentives, practices can build multidisciplinary teams without absorbing all labor costs, while hospitals benefit from increased downstream referrals.

Chronic care models (CCMs)
CCMs offer another pathway by enabling practices to bill for non–face-to-face management activities. Practices that implement CCM typically assign oversight to a physician-APP team and build structured processes for regular patient contact, symptom monitoring, and coordination. The reimbursement generated can support hiring a triage nurse, pharmacy technician, or part-time dietitian—roles that help lighten clinician workload and accelerate time-sensitive care.

Dedicated IBD service lines
Several larger community groups have created dedicated IBD service lines—essentially an IBD “center within a center”—with physicians, dietitians, behavioral health specialists, and navigators integrated into a single pathway. These models most closely resemble academic IBD centers and offer clear benefits for patient outcomes and practice growth, though they require substantial investment and cultural alignment.

To help practices operationalize integrated IBD care, the working group outlined a four-step approach:

1. Assess current workflows and resources. Practices should map out their processes, staffing, and existing gaps.

2. Conduct a structured gap analysis. This can reveal unmet internal needs and opportunities in the local market, such as favorable value-based contracts or potential hospital collaborators.

3. Evaluate potential care models. Practices should consider which options best match their size, staffing, electronic infrastructure, and payer mix.

4. Secure organizational buy-in. Leaders must present a clear and compelling case that integrated care improves patient outcomes, enhances staff satisfaction, and generates new revenue streams while supporting broader practice goals.

According to Ritter, each practice “needs to continually reassess how successful their model is and be open to revising the model as their practice and healthcare policies and economics change over time,” he said.

Cohen characterized the initiative as “a wonderful first step in starting this important conversation,” she said. “Future directions include career mentorship for fellows and early-career physicians, formalized advocacy to payers, implementation of intestinal ultrasound, and data collection on clinical outcomes, financial viability, and qualitative measures in these models.”

The published article is based on an in-person AGA-sponsored conference supported by grants from Bristol Myers Squibb, Takeda Pharmaceuticals, Eli Lilly, AbbVie, and Johnson & Johnson Innovative Medicine. Ritter has served on speaker bureaus and/or on advisory boards for Bristol Myers Squibb, Takeda, Eli Lilly, AbbVie and others. Cohen has served on speaker bureaus for Eli Lilly, AbbVie, and Takeda and participates on advisory boards/consults for Takeda and others.

Impact of the AGA’s IBD Community Care Initiative

Erica R. Cohen, MD, Director of the Chronic Care Inflammatory Bowel Disease Program and Research at Capital Digestive Care in Chevy Chase, Maryland, discussed the importance of the IBD Community Care Initiative in an interview with GI & Hepatology News.

Your survey of 102 community providers identified four major barriers to integrated IBD care—compensation, access, lack of multidisciplinary resources, and operational inexperience. Which of these barriers did you find most surprising or most urgent, and why?

Dr. Cohen: I graduated from the Cedars-Sinai IBD fellowship and decided to pursue a career in my hometown community. I realized very soon in the clinical trenches that these are very real barriers, so none of them are surprising to me. I have seen these challenges lead to subspecialty-trained physicians avoiding cognitive care management in favor of procedural-based practices.

I am lucky that Capital Digestive Care values cognitive care delivery and allowed me to explore solutions to many of these challenges. In this quest, I realized there are many IBD-focused community providers across the country who are light years ahead of me in answering these questions. I asked Dr. Tim Ritter, who had been mentoring me on setting up my own clinic, if he would co-chair the AGA IBD Community Care Initiative so we could systematically identify the challenges, explore solutions already in practice around the country, and create space to continue this conversation.

The initiative outlines several community-ready care models—APP-led programs, chronic care models, third-party platforms, joint ventures, and IBD service lines. Based on your workshop discussions, which model do you believe is most feasible for an average mid-sized community GI practice to adopt first, and what early wins can they expect?

Dr. Cohen: This depends on the practice culture, available financial support, local hospital interest, and identification of provider champions. Using a third-party platform may be the easiest to implement because there is no upfront financial cost or resource requirement. If the platform utilizes risk-based contracting or chronic care reimbursement, the practice should see a financial upside relatively quickly, and there are data showing that these programs can decrease acute care utilization and improve quality of life. These platforms can reach a larger volume of patients than an APP-led program or a chronic care model but run the risk of lack of oversight from the practice, additional administrative burden, and further limiting the scope of gastroenterology practice.

Many providers cite poor compensation for cognitive, complex care as a core obstacle. What strategies—such as hybrid RVU/salary models or stipends tied to cognitive-care responsibilities—do you think have the greatest potential to gain traction in community practices? What makes these approaches realistic?

Dr. Cohen: I was very surprised to find during this workshop how many practices already follow an equal-shares model. I think this is wonderful but very hard to change culturally, as it requires all partners to agree that compensation models should be realigned. The most realistic approach is to create stipends for IBD Program Directors with defined expectations and deliverables that benefit both the physician and the practice. Financial support can be drawn from CCM billing, clinical research participation, community marketing, provider education, or oversight of infusion services/prior authorization. 

Your data show that only 6% of community practices have a formal urgent-care process for IBD, despite widespread agreement on its importance. What are the simplest, most immediately implementable steps practices can take to improve same-day access and reduce ER visits?

Dr. Cohen: Small changes can lead to improved access for patients and less manual work for clinicians.

• Educate patients on what symptoms are defined as urgent. The Quorus urgent-care toolkit has handouts that practices can provide to patients through email blasts or at clinic visits.

• Have an urgent phone line (can be managed by a secretary, infusion MA, or prior authorization staff) that uses a templated form to determine the urgency of the visit and sends it to a team member.

• Have one APP urgent-slot patient visit open per day.

These small changes create a team-based system approach to addressing urgent concerns.

Many community practices lack dietitians, behavioral health specialists, and trained navigators. You propose a “Physician/APP co-champion” model. What qualities make for an effective co-champion, and how can practices identify or cultivate them when resources are limited?

Dr. Cohen: Effective co-champions are clinicians who are interested in focusing their practice on IBD management. The upfront time required to set up these internal processes will benefit clinicians in the future by reducing clerical and administrative burdens and allowing them to focus on direct patient care.

To best operationalize integrated care, you outline four steps—assessment, gap analysis, model selection, and presenting a case. From your experience, which of these steps tends to derail practices most often, and what guidance would you offer to help leaders keep momentum during implementation?

Dr. Cohen: It is atypical for practice leadership to consider cognitive-care clinical pathway development for IBD. There are community practices whose leadership has successfully implemented IBD care models, but only a minority of panel members worked in this type of system. Most commonly, these models were developed from the ground up by motivated clinicians who wanted a sustainable practice. From a clinician perspective, building these care models can seem daunting, as we were never taught how to create a business model and pitch. Through this initiative, we hope to lay the groundwork for more widespread utilization.