Anna Flattau, Alumni Professor and Chair of Family and Community Medicine and Enterprise Chief of Primary Care Services at Jefferson Health

Summary

Becker’s Healthcare Podcast Summary

Episode Title: Anna Flattau, Alumni Professor and Chair of Family and Community Medicine and Enterprise Chief of Primary Care Services at Jefferson Health
Date: January 29, 2026
Host: Laura Dardo, Becker's Healthcare
Guest: Dr. Anna Flattau

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Overview

This episode features Dr. Anna Flattau, who shares innovative approaches and strategic priorities from her role leading Family and Community Medicine and primary care at Jefferson Health. The conversation dives into Jefferson’s evolving care delivery models, access-focused initiatives, lessons from their virtual primary care rollout, upcoming challenges in Medicaid and access, and areas for growth over the next few years. Dr. Flattau’s insights reflect a deep emphasis on meeting patients where they are—digitally or in-person—and delivering whole-person, relationship-based care at scale.

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Key Discussion Points and Insights

1. Dr. Flattau’s Role and Jefferson Health’s Strengths

• Dr. Flattau leads both the academic Family Medicine department and serves as system chief for primary care.
• Jefferson Health is a large system with 32 hospitals, 700 ambulatory sites, and 150 primary care sites, serving around a million patients.
• The system is a product of recent mergers, leading to diverse perspectives and innovation.
  • Quote: “The strength that comes from the diversity of experience across those different legacy organizations… really strengthens our ability to come up with innovative, critical, scalable solutions for the communities that we serve.” (00:37)

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2. Most Important Recent Initiatives (01:42 – 07:08)

Virtual Primary Care Expansion

• Jefferson significantly expanded virtual primary care, distinguishing it from virtual urgent care.

• Focus on relationship-based, continuity-driven care, complete with patient panels and collaboration with specialists.

• All patients are educated about the virtual primary care option during scheduling.

• Widespread appeal: adopted by people across ages, tech-literacy, health status, and socioeconomic backgrounds.

  • Notable story: a 102-year-old joined the program.

• Added roughly 500 new virtual primary care patients monthly, with potential for accelerating growth.

• Targeting gaps by funneling patients from emergency rooms and other high-demand areas.

  • Quote: “We have a patient who’s 102 years old who joined our virtual primary care service. Patients of a wide range of disease complexity, many…with previously uncontrolled chronic diseases…are just not getting to a clinician, who have joined our virtual primary care practice and whom we’re now able to manage without them having to take a day off from work….” (04:34)

Lifestyle Program Launch

• Launched a year-long, structured telehealth program focusing on the six pillars of lifestyle medicine: diet, exercise, sleep, social connection, stress management, and risk avoidance.
• Group visits co-led by a dietitian and nurse practitioner.
• Goal: 5,000 enrollees in the first three years.
• Integrates with behavioral and whole-person care already at Jefferson.

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3. How Clinicians Adapted to Virtual Care (07:08 – 09:17)

• Clinicians demonstrated strong problem-solving and adaptability.
• Developed logistical solutions, such as:
  • Providing blood pressure cuffs for at-home use.
  • Coordinating with labs for vital sign measurements.
  • Facilitating self-testing (e.g., STD kits mailed to patients who then return samples).
• Fewer in-person follow-ups than expected; virtual care sufficed for most patients.
  • Quote: “They’ve become excellent at ensuring that everyone can get a blood pressure cuff...We’ve become very creative about getting the testing supplies for self-testing...So there haven’t actually been a whole lot of problems that we’ve been unable to solve.” (07:50, 08:43)

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4. Strategic Priorities and Headwinds for 2026 (09:27 – 12:25)

Care Transitions and Outreach

• Focus on comprehensive transitions from hospital to home, beyond immediate discharge to ongoing care.
• Expanding telehealth transition appointments, ensuring follow-up and connection to primary care—either traditional or virtual.
• Special programs for:
  • Community-based palliative care.
  • Severe substance use disorder: expanding the Scheller Bridge program for complex primary care and support (includes management of hepatitis C or PrEP).

Expansion of Home-Based Care

• Incorporating more home visits and home-based primary care for post-hospital patients.

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5. Anticipated Challenges: Medicaid & Insurance Landscape (12:45 – 14:52)

• Top concern: changes in Medicaid requiring frequent re-enrollment, adding bureaucratic and SDOH (social determinants of health) barriers.
  • Dr. Flattau recalls her years in safety net organizations and the burden of paperwork for vulnerable patients.
• Worry about patients losing insurance eligibility—both Medicaid and ACA-related shifts.
  • Quote: “Insurance eligibility is a social need and a very important one, of course, in healthcare. So something that we need to have front of mind and also not to underestimate the complexity of those processes and the amount of support that, that our patients are going to need to navigate them.” (14:33)

Addressing These Challenges

• Training care managers, social workers, and community health workers to help patients with insurance navigation.
• Partnering with community organizations for support.

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6. Growth Opportunities at Jefferson Health (15:21 – 16:32)

• Doubles down on consumer-driven models, virtual care, and AI integration.
• Future growth will be shaped by evolving patient demands and new technologies, not just increased volume.
  • Quote: “Our business model is changing…with more virtual care, with more consumer driven…health initiatives, including supported by, by AI. Healthcare is going to change.” (15:31)

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Memorable Moments & Notable Quotes

• “We have a patient who’s 102 years old who joined our virtual primary care service.” (04:34)
• “They’ve become excellent at ensuring that everyone can get a blood pressure cuff when they need it…we’ve become very creative about getting the testing supplies for self-testing…” (08:11)
• “Insurance eligibility is a social need and a very important one, of course, in healthcare.” (14:33)
• “The way to grow is to embrace that and to build according to what people and communities want.” (15:31)

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Timestamps for Key Segments

• 00:37: Dr. Flattau introduces herself and describes Jefferson Health’s strengths
• 01:42: Discussion of top recent initiatives: virtual primary care and the lifestyle program
• 07:08: Clinician adaptation to and surprises with virtual care
• 09:27: 2026 priorities: transitions programs, outreach, and special populations
• 12:45: Greatest challenge for next year: Medicaid and insurance changes
• 15:21: Future growth opportunities: embracing virtual, AI, and consumer-driven care

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Tone & Language

The conversation is candid yet optimistic, showing a compassionate, patient-centered approach. Dr. Flattau’s style blends real-world anecdotes and practical strategies with a forward-looking, innovative mindset—always focused on improving access and whole-person care for her communities.

Transcript

[A]

This is Laura Dardo with the Beckers Healthcare podcast. I'm thrilled today to be joined by Dr. Anna Flattel, alumni professor and chair of family and Community medicine, as well as system chief of Primary care at Jefferson Health. Dr. Flattell, it's a pleasure to have you on the podcast today.

[B]

Thank you for having me.

[A]

Absolutely. Now, I'm excited to hear from you because I know Jefferson is very much on the forefront of a lot that's happening within healthcare. Transformation in delivery of care, expanding access and more. And so I'm excited to hear some of the things you've been up to as well as your perspective, perspective on the future. But before we dive in, can you tell us a little bit more about yourself and Jefferson Health?

[B]

Of course. So I'm a family physician. I practice and see patients still. And as you noted, I have a dual role at Jefferson. I lead our academic department of family medicine, the university, and I'm also the system chief for our primary care system. And like many institutions, you know, Jefferson Health in its current state, which has a regional presence across eastern Pennsylvania and southern New Jersey, is the result of a merger of multiple organizations over recent years. I think one of the things that's really impactful is not just our size, but also the strength that comes from the diversity of experience across those different legacy organizations that really strengthens our ability to come up with innovative, critical, scalable solutions for the communities that we serve.

[A]

That's amazing to hear and certainly such an important, important aspect of understanding your patient population and what each needs in order to be successful and better access care. Now, when you're thinking of the last year or so, what was the most important initiative you led? What did you do and what were the results?

[B]

Yeah, so that's a hard question because we've done a lot over the past year or two, so it's hard to think of just one. But when we think about what's most important for our initiatives, it's really thinking of the scale of our organization. So we're a 32 hospital system and we have 700ambulatory sites and about 150 primary care sites. And in my role leading our primary care system, that's approximately a million patients in Jefferson primary care whom we serve. So when I think about the most important initiatives from our past year, it's really thinking about how we can further our model of care and think about better, more person centered ways of creating access for our patients and communities. And that's access not just in getting the appointment that people need, which certainly is Critical and is a constant focus for us. But, but in giving people access in the way that they want. Sometimes that's virtual, sometimes that's in person, sometimes that's at home. To make sure also that they get the comprehensive care that they need once they make it through our doors and have connected with our system. So I'm gonna describe two initiatives that get at that that we've launched in this past year. One is that we've really expanded our virtual primary care service. And that's a service that many organizations have been growing and we're no exception to that. What I think has been very special about the way we've structured, built and scaled our virtual primary care services is that we really made an effort to connect it with the deep roots of what primary care is. Relationship centered, comprehensive, focused on continuity over time, really meeting the entire set of patients needs in collaboration with specialists and other colleagues as needed. So when we set up our primary care service, we were very careful to delineate it from our also very important virtual urgent care offerings and really talk to patients as they schedule about becoming part of a panel with a personal physician or advanced practice practitioner in order to really root in that important aspect of primary care, which we know is the driver of individual and human and community health. So we've actually routed that service into all of our access points. When people call Jefferson, when they look on our website, when there's a referral internally for primary care, every single patient gets an explanation of what virtual primary care is. A traditional primary care practice, but all virtual. Same scope of practice, same commitment to their health. And we found that that's extraordinarily popular with patients who are seeking primary care at Jefferson. What's been very interesting also is initially we thought that maybe this would appeal more to healthier or maybe higher income people or people who are more tech savvy. It turns out that all sorts of patients are voting with their feet to join our virtual primary care services. So people of all sorts of different ages. We have a patient who's 102 years old who joined our virtual primary care service. Patients of a wide range of disease complexity. Many, many patients with previously uncontrolled chronic diseases like hypertension or diabetes who are just not getting to a clinician, who have joined our virtual primary care practice and whom we're now able to manage without them having to take a day off from work or leave their children or otherwise overcome the obstacles to an in person appointment. And even some highly complex patients who come out of our hospital and are at home. We found that we've been able to effectively manage through our highly experienced virtual primary care clinicians. And we've also noticed that people from all different socioeconomic backgrounds have signed up. We've mapped people's addresses to the area deprivation index, which is an indication of how rich or poor the neighborhood is where you live. And we found that people from across the entire socioeconomic spectrum are signing up for virtual primary care. So just from our kind of standard scheduling processes, we're gaining about 500 new patients a month who did not previously have primary care who are joining virtual primary care. And I think that will only accelerate over time as we hardwire some pipeline from our emergency rooms and other areas where we know that there's unmet demand and offer this really important option that we found to be very effective in meeting people's needs. The other program I'd like to mention which actually launched today is our lifestyle program. And I'm going to go back to what I said originally about access being not just getting your appointment, but getting everything you need. We're very committed to whole person primary care, had long standing services, for example for integrated behavioral health. And our lifestyle program is a structured year long program to help people make the behavior changes that as human beings we all struggle to make, but that are actually extraordinarily impactful for both preventive health and management of chronic disease. So that's a program that over the course of a year in telehealth based group visits co led by a registered dietitian and a nurse practitioner, will address the six pillars of lifestyle medicine, Diet, exercise, restful sleep, social connection, stress management and avoidance of risky substances. And we're really excited. We're committed to enrolling at least 5,000 people over the next three years in this year long program, which I think will be transformational for how we provide care.

[A]

That's amazing to hear. I think both of those options, the virtual primary care as well as the lifestyle program. And congratulations on the launch, it seems like it covers huge needs for patients and really puts them in a position to be healthier overall. I'm curious, when you look at the growth and popularity of the virtual primary care program, have the clinicians that are working and meeting with patients had to do much differently or adjust to, I guess, any of the things that come along with virtual care visits, is there anything you've been surprised by as the program has grown and developed?

[B]

So I think they've been done an incredible job at finding solutions to problems that present themselves and that's perhaps the definition of primary care.

[A]

Right.

[B]

We, we look at the, the, the issues that patients bring to us and we find solutions. And they've been very creative. Not, not just the physicians and the advanced practice clinicians, but also our administrative leadership of that program has really done an extraordinary job in being solutions oriented. So they've become excellent at ensuring that everyone can get a blood pressure cuff when they need it, so that we're able to manage hypertension remotely. We've become excellent at ensuring that we can get sometimes vital signs, including weights, at a laboratory facility, which many of them will do. We've become very creative about getting the testing supplies for self testing for certain types of tests to patients so that they can, for example, get the STD testing in their homes and then bring those results back to the lab. So there haven't actually been a whole lot of problems that we've been unable to solve. I think it really comes to having focused administrative and clinical medication to helping patients to get what they need. When patients do need an in person appointment, we can bring them into any of our 150 sites in order to have an in person exam. When we started the program, I think we all expected that that would happen somewhat often, but it's actually been pretty rare that that's been necessary. We found that we've been able to, to the large extent, really manage comprehensively through virtual means.

[A]

That's amazing. Thank you so much for sharing a bit more about that program. And now when you look ahead, what are some of the big priorities and headwinds you're focused on for 2026?

[B]

So for 2026, as for 2025, we've really been looking at what our commitment is to the population that we serve. So that's the million people who are in our primary care system, but also the people who come into our hospitals who may not have access to high quality primary care. So we've been giving a lot of thought for 2026 on how to improve Transitions programs, not just for the transition the day you leave the hospital or that week or those 14 days, but how to build out those programs to ensure people are connected to ongoing care that again is whole person and comprehensive. So we're expanding dramatically our telehealth transitions of care program to make sure everybody leaving the hospital can get that appointment. If not with their primary care physician, which is always plan A, then with a transitions physician or APC who can ensure that they have a smooth exposure experience leaving the hospital and transitioning back to their home. But Once we bring people into that transitions program, we are going to make sure that they're connected with primary care and those who are not. The virtual primary care option allows us to expand access very rapidly to ensure that patients have a safe landing place. So we will offer them, as we do to all of our patients, an option between the traditional in person primary care or the virtual primary care and ensure that we have our arms around those patients for their long term care. And then of course, once they're enrolled, they have access to behavioral health options, lifestyle options, social service supports and so on as part of that core foundational layer. When we think about Transitions, there are a couple of special populations in there and we're working very hard for 2026 to ensure that we design the right programs for them. That includes people who may benefit from palliative care. So we are expanding our community based palliative care services to new regions under that trans care umbrella. We're also looking at how some of our national model programs here for people with severe substance use disorder can be expanded so that from all of our hospitals, patients who are suffering from severe substance use disorder, which often leads to recurrent emergency medicine visits or recurrent hospitalizations, can transition into a complex primary care model. The Scheller Bridge program that we've established, that we've proven can help people get into recovery and also manage their comprehensive primary care needs, as well as conditions they may have like hepatitis C or the need for injectable prep that can also be administered in that setting. And finally, we're thinking in terms of transitions, not just for those telehealth visits, but how to expand our home based primary care offerings to ensure as needed visits for that transitions population. So those are some of our ambitions for 2026 as we think about the sort of global needs, not just event oriented, but global needs for that population and those communities that we serve.

[A]

That's amazing to hear. You know, it makes a lot of sense to have that type of focus and energy and looking at where people can really benefit the most from additional services and opportunities to have their more comprehensive needs met in the primary care setting. A primary care model. What do you think the hardest thing you'll have to do next year will be?

[B]

You know, there's plenty of headwinds in health care, no shortage of them. I think what I worry most about is the changes to Medicaid, including those that will require re enrollment very frequently because I, you know, having worked in safety net organizations for most of my career and FQHC for Many, many years. I know how burdensome that paperwork is, and it will create an enhanced social determinant of health barrier to receiving care for many of our patients. So we're going to need to organize ourselves to help them go through that bureaucratic process much more frequently than was previously the case due to the changes in the rules around Medicaid. So that's. That's certainly top of mind for me. Also concerns around people just losing their insurance, which some, with some of the. The changes in insurance eligibility across Medicaid and aca, I think everyone is worrying about those. As soon as I can get my patients in the walls and we have them, you know, cared for by our team, I know that we can do everything to meet their needs and build the programs that they need, but ensuring that they have that coverage up to date and that their enrollment is in place is something that is concerning, that's helpful to understand.

[A]

And I think, you know, so many organizations out there in health systems, big and small, are having similar issues that they're trying to troubleshoot in terms of, you know, figuring out what the barriers are and then understanding what some of the changes coming down the pipe will be from the federal government and state level and in looking at insurance and access. And so it seems like you're building out network in a smart way with a variety of different contingencies. No matter, you know, where things evolve over the next several months, you'll be able to know who's out there and provide services that they're needing.

[B]

Absolutely. And, you know, we talk about social needs a lot. Insurance eligibility is a social need and a very important one, of course, in healthcare. So something that we need to have front of mind and also not to underestimate the complexity of those processes and the amount of support that, that our patients are going to need to navigate them.

[A]

Absolutely. Are you thinking of making any new hires to cover some of those areas, or is it primarily looking at how do your current teams just think one bit differently to make sure that they're getting that space covered and that patients know what their options are?

[B]

We're definitely looking at ensuring that we have our care managers, our community health workers, our social workers trained to be able to manage some of those demands? Absolutely. In conjunction with community partnerships.

[A]

That's great to hear. Now, before we wrap up, I wanted to talk about growth as well. Where do you see some of the best opportunities for growth at Jefferson Health in the next two to three years?

[B]

So I think the demand for healthcare is always there. It's really A matter of meeting patients in the way that they need. Our business model is changing, right? You know, with more virtual care, with more consumer driven, you know, health initiatives, including supported by, by AI Healthcare is going to change. And I think the way to grow is to embrace that and to build according to what people and communities want. So, you know, as I think about growth, I think virtual is going to continue to be a really strong focus for us. I think that the sort of experiential and relational aspects of health care that are demonstrated through primary care, but also through programs like our lifestyle program, will be increasingly important. I think that a lot of the artificial intelligence technology will allow us to free time to have better access and more comprehensive access for our patients. So I think there's a lot of ways that we will need to grow, not just in quantity, but in a way that evolves the way services are.

[A]

Provided along those lines, that's helpful for understanding, to understand. Dr. Flattau, thank you so much for joining us on the podcast today. This has been such a fun conversation. You know, I learned a lot. It seems like you've got truly some amazing things happening there at Jefferson Health. And I look forward to seeing you at our annual meeting too in April. I know you'll be speaking on a panel and really bringing some of this great expertise and insights into some of the broader strategic things happening in the healthcare space. So looking forward to seeing you then.

[B]

Thank you so much for having me. I look forward to it as well.