What do you do when you know what your patients need, but the system has no clear way to pay for it?
For Josh Gregoire, DNP, RN, AVP of Quality and Population Health at Valley Health System in New Jersey, the answer has never been to stop. It has been to find another way.
Josh leads quality and population health for an ACO managing nearly 90,000 patient lives. His work includes programs many health systems struggle to fund or even start: a Food as Medicine program for patients with diabetes, a growing LGBTQ primary care center, and an IRB-approved randomized controlled trial focused on Black maternal health.
These programs began with strong ideas, the right partners, and a leader willing to keep moving when the first answer was no.
The Chaos: When What Works Is Not What Gets Paid For
Healthcare is full of good ideas. The problem is that many of the things that help people stay healthy are not covered by traditional payment models.
Josh saw this clearly with a group of patients with diabetes. These patients were stuck. They had tried medications, diet changes, and other care plans, but they were not seeing the progress they needed. The evidence pointed to Food as Medicine. But medically tailored meals and nutrition support are often not covered by insurance.
For many programs, that would have been the end of the road. Josh found another path.
He brought the idea to Valley’s foundation, secured a gift to fund the program, and treated it as a proof of concept. The team measured outcomes, tracked patient engagement, and built a stronger case for future support.
The Leadership: Managing by Influence
Josh calls his leadership style “managing by influence.” He does not rely on a large team or direct authority over every person involved in the work. Instead, he focuses on building urgency, framing the problem clearly, and connecting the right people.
His LGBTQ primary care program started with a conversation at a playground. From there, Josh made the right introductions, helped leaders see the need, and supported the case for a physician FTE. The result was a thriving primary care center focused on LGBTQ health.
No formal authority was required. Just clear vision, strong relationships, and the right people in the right room.
Josh is also honest about what strong leadership requires. The best leaders stop trying to have every answer. Instead, they create teams that can solve problems together. As Josh says, “When you can engage people closest to the problem in that work, you create an army of problem solvers.”
The Success: Outcomes That Open the Next Door
The Food as Medicine program showed meaningful A1C reductions. Josh shared that each one-point A1C reduction is tied to about $1,200 in annual savings per patient. In other words, the program helped cover its own cost. Those results helped Josh build the case for the next project: an IRB-approved randomized controlled trial focused on Black maternal health. Each success became the foundation for the next ask.
Healthcare needs more leaders who see a “no” from a payer as a detour, not a dead end.
This episode is a practical lesson in creative funding, community partnership, leading through influence, and building programs that improve patient outcomes. Listen to the full conversation.
Episode Chapter Guide
01:38 Journey from Bedside to Leadership
06:16 Innovative Approaches in Population Health
09:24 Success of the Food is Medicine Program
11:29 Building an LGBTQ Primary Care Program
20:09 Expanding into Maternal Health
23:32 Leadership Wisdom and Advice
Full Transcript
AI-generated transcript. Accuracy may vary; please excuse any transcription errors.
Angela Adams, RN: Welcome to Success and Chaos, a healthcare podcast where each episode is dedicated to driving success amidst the constant change and uncertainty. My name is Angela Adams, the CEO at Inflo Health.
Kandice Garcia, RN: And I’m Kandice Garcia, CEO of Tungsten QI Partners and director of the ACR Learning Network.
Angela: We are so excited to have our guest today, Josh Gregoire, a nurse, a change agent, a quality leader. He runs quality and population health for an ACO managing almost 90,000 lives at Valley Health System in New Jersey. Josh has a track record of building programs that the system frankly wasn’t ready to fund. From food as medicine to LGBTQ primary care. By finding creative paths and bringing the right people along, Josh, welcome to Success and Chaos.
Josh Gregoire, DNP, RN: Thanks for having me.
Angela: Absolutely. I’ve been really excited about this since we learned about all of your great success that you’ve been driving in healthcare. Let’s start back. You started in cardiothoracic surgery, as did I, which I love. You went into case management, you moved into population health and quality. What’s the through line? What experiences shaped how you lead today, and how did that transition kind of make who you are today?
Josh: Yeah, so I mean, I think starting out as a bedside nurse and getting that clinical experience, you know, I started to see that there was potential for me to impact my patients’ outcomes in a different way. And so I became a case manager and I found it really interesting because my responsibility was beyond the four walls of the hospital. So I had to be thinking about not just what was going to happen for patients under my care today, but how were they going to get home safely? How are they going to have what they needed so that they weren’t coming back to us and being re-hospitalized unnecessarily?
And I remember this one story when I was a case manager. I had a patient that needed to go home on Lovenox. We were trying to get the patient out the door safely. And there were a lot of issues with them being able to fill their medication, getting insurance coverage, being able to afford the medication. And so they were ready to go. Their ride was there to pick them up, and I wanted them to get home safely. But I needed to make sure that they were able to have what they needed to start their medication at home.
So I remember going to my director at the time and asking her, if I can get this medication covered, you know, through our patient assistance funds and can get this to the patient, would you be okay with me bringing this to the patient’s house? And the patient lived in New York City, so I actually ended up taking a taxi cab to deliver the Lovenox medication to the patient’s home. But I was able to get them home safely and make sure they had what they needed. And I knew that was going to make the difference for the patient.
And I’ll never forget my boss had told me, you know, you got to do whatever you got to do to help this patient. And it was a really different mindset than we’re accustomed to in healthcare, where we tend to be very structured and have very specific rules. And this was thinking more globally from a population health mindset and saying, what is it that this patient needs and how can we help them?
Angela: Man, I love that. See a problem, solve a problem. You definitely live that as a mantra. I can tell that. I would say that each one of us on this call probably faced multiple of those examples throughout nursing. And it’s crazy to me that the nurse who’s left at the bedside doing a million things is the one also left thinking, if this patient doesn’t get this thing and I don’t take this to their house, I mean it’s just like overwhelming everything that falls on the nurse’s plate, but that was above and beyond for sure.
Kandice: Yeah, I like to see though the professional problem solving that we see here, the ability to understand what the challenge is and to meet it with such a creative solution, like that is very organization specific. It sounds like you had an environment that your leader created where you were able to think outside the box and not be afraid to ask for permission. Even if it seemed like, hey, this is not something that we do, you were able to actually — it sounds like you were inspired to think outside of that framework and do something new and different and they let you.
Josh: Yeah, I think it was fueled by the emergence of the bundled payment initiatives in our cardiac patient program. And we were really starting to think differently about — you hear the classic example of, you know, the patient with COPD that’s revolving door coming back to the emergency department when what they really need isn’t more medication, but maybe an air conditioner so that they can have a cooler apartment and have cleaner air that they’re breathing in the hot summer months. And, you know, if we were just to spend this money on an air conditioner, instead we could save so much and really actually address the root cause of what this patient’s issue is. And I think some of that thinking starts to infuse into healthcare in different ways when we have these alternative payment models that are really driving innovation.
Kandice: Yeah, you know what? It makes me think about problem solving — it’s like creativity, but it’s also within the constraints of your environment. And I think that what’s so interesting about the path that you’ve been on and the work that you’ve done is that you really started to tackle the constraints of funding for these programs that you know are root causes for your patients. Can you tell us a little bit about your food is medicine program for diabetic patients and how you funded that and how you got this to be part of the care pathway for the patients?
Josh: Absolutely. So working in a value based model, we have contracts for about 90,000 patient lives through value based care, which means that there’s a component of fee for service just like usual, but there’s also a component of value based incentives that you can get on the back end if you’re able to reduce the cost of care while also maintaining quality. So that’s where the innovation starts to come in. How can we improve our patients’ quality outcomes, but also make sure that they’re utilizing the right care, the right time, the right place?
And so we had a group of patients in our diabetes center who were really facing what we call clinical inertia. They’re reaching that point where they feel like, I’ve tried the medications, I’ve followed the diet, I’ve done everything that my doctors are telling me to do, and I’m still not seeing the outcomes that I need to see. And you know, maybe I’m just not somebody that’s gonna get better. And it’s really deflating for patients to reach that point, but it’s actually quite common.
And so we learned about ways that you could start to address clinical inertia and help to get patients over the hump using food. And I’d heard a really innovative program at Geisinger where they did a food as medicine initiative and they were delivering food to patients in the diabetes program, measuring their A1Cs, measuring certain outcomes to see how they could improve. And they saw a lot of success.
Well, I am not really the expert in food management and delivery. I’m a nurse. I focus on the clinical piece. So I was able to find an organization that can provide food as medicine, nutritious meals ready to eat, as well as nutritionist support. And what I thought was that it would be a really great supplement to our program. But we reached the classic example where things that really work for patients aren’t things that are reimbursed or funded by traditional insurance models.
And so we have a really great community here at Valley, and we have a number of different resources that we can go to and ask for help for financial assistance to fund projects and demonstrate outcomes in certain patient populations. So I said, well, what if we were able to get a gift that could support this program as a proof of concept to show the impact of using medically tailored meals and nutritionist support on patient outcomes in the diabetic patient population.
Angela: That is some forward thinking right now. I go to all these conferences and we sit there and they talk about I don’t know how to get all these programs funded. I don’t know what to do. And you just like took the bull by the horns, went out there to the community, which I love because honestly, I also live in a community that if I go to some of the community leaders and say, hey, we really need this, they find the funding for it somehow, some way. So I love that you took that initiative. Also change agent behavior right there. So what were some of the impacts that you guys saw from the Food is Medicine program? Did you guys have successful outcomes?
Josh: We did. It was a small sample, but we were able to demonstrate meaningful A1C reductions in the patient population. We know that for every one point A1C reduction, it correlates to about a twelve hundred dollar per member per year savings in diabetic patients. And so we essentially covered the cost of our program with the impact that we were having. But I think what was most impactful was the patient engagement. So once we started getting people bought in with the meals and the nutritionist support, once they started to see that they were making progress, they started to believe that they could manage and handle more.
And so that’s where we used our population health approach, having our nurses who had established relationships with them start to engage them in additional gap closure. So for example, we know diabetes affects the eyes, and patients with diabetes really need an annual diabetic eye exam or a retinal photo. So we were able to get them to come into our center to sit in front of our retinal camera and get the photo taken. And so they started to feel like I could do one more thing and I could take a look at another thing that could help me get a better outcome.
And this was really important because we know that retinal disease tends to be silent. You may have something brewing until you start to lose your vision, you don’t know that it’s a problem. So we were able to identify a significant amount of eye disease in this patient population and patients were not aware. So this was something where we were able to close additional quality gaps because we helped patients to see that they could do this and they could manage their care differently.
Angela: That’s amazing. What a great success story. So in our conversation, you told us this amazing story of you were having a conversation on a playground one day. And it led you to build another phenomenal program. Talk to us about how a conversation on the playground led you to build an LGBTQ primary care program.
Josh: So it was during COVID — not the peak of COVID, but a little bit after — and I was at a gay dad’s meetup and our kids were playing on the playground and I was talking to this one person and he was saying, you know, I just wish I could do something different. My job is so stressful. I just wish I could do something more meaningful. And I said, well, what do you do? And he said, I’m an infectious disease doctor. And I said, well, yeah, I can really understand the type of pressure that you’re under.
And I said, well, what would you want to do? How would you want to pivot your career? And he said, well, you know, I spend some time working in the LGBTQ clinic and providing care to LGBTQ patients. And it’s really rewarding. It’s really fulfilling. And I just wish I could do it full time. And I said, well, why don’t you? And he said, where am I going to do that? And I said, well, why don’t you come to Valley?
And we didn’t have an LGBTQ program at the time for primary care. And I was just an active member of our LGBTQ steering committee and sort of a leader that supported our committee’s growth and progress. And, you know, with no authority to do so whatsoever, I attempted to recruit a physician.
I knew the right people. I went to our senior vice president and I said, listen, we’ve got this really amazing doctor. We’ve been trying to impact our LGBTQ care differently. And I know it’s really hard to ask for an FTE, to ask for a new position, especially a physician. And I said, we’ve got this primary care program and they’re recruiting for new physicians. What if we approach this as a primary care physician that specializes in LGBTQ health? And the rest is sort of history. I got the right people together, they hit it off, and now we really have a thriving, comprehensive primary care center for LGBTQ care.
Angela: That is so amazing. I love how you just — there’s not many people that take an initiative on a conversation, go behind the scenes and get all of those things done. I mean, I think that is very commendable because I would say most people would leave that conversation and be like, wouldn’t it be cool if we had that thing? But you taking that action — what do you think drives that in you? What do you think led to that in life, because I think it’s a characteristic that a lot of us look for when we’re hiring our teams?
Josh: Well, I’m not very good at taking no for an answer and I like connecting people to solve problems. I think a lot of problem solving in healthcare leadership is making sure that the right people are talking. And, you know, we can frame the issue, we can present the facts, but we really have to get people working together and talking to each other. And I think a lot of times, when we have problems that we’re facing, we’re just not getting the right people together, getting the right people to understand the issues and to hear each other and their perspectives.
And so a lot of what I do in my success is just making sure that people are communicating. And I think that’s an example of what I did. And I think also a lot of the success of programs like this is it has to come from the people within an organization and the people that are closest to the patients and the work. And our steering committee had been talking about some of the gaps that they saw for some time. So I was able to go back to them and share, like, because of your voice, because of your advocacy, we were able to identify this gap, get this physician in the door, open this center. And I think it makes it more personal and it makes it something that belongs to people. And I think that’s the type of support that you need for programs like this to thrive.
Angela: I love that.
Kandice: It’s kind of like where vision meets innovation meets skill. It’s like you have the perfect combination to push the boundaries of how we provide care and how you lead your teams. When we teach leadership in the program that I run, it really is — the best leaders are the best at knowing who to talk to, how to frame it, and how to meet everybody where they’re at to bring them towards a common goal. And it sounds like this is where you are an expert in leadership.
Tell me a little bit about your team. Are you a one man show? I know you talked a little bit about the frontline staff and them participating, but how do you kind of lead a team to do what you do?
Josh: Yeah, so quality and patient safety is never gonna be a department where you’re gonna have a significant amount of people. And a lot of my accomplishments as a leader throughout my career have been managing by influence. And I think managing by influence is really challenging because you have to get people to want to do things. You have to get people to believe in something. And so a lot of what I do is — I do have a team, a phenomenal team — but they’re doing the same work that I am in that they can’t be out there solving every problem for every person. They need to be: how can I create this urgency in the teams that I work with to recognize and address things? How can I get people closest to the problem to think about what the best solution is and how can I listen to them?
You know, I think a lot of times in leadership, one of our failures is thinking that we have it all figured out and trying to solve problems for people instead of bringing people together to identify what the barriers are and what some innovative or new ways that we could solve this problem might be. And so I think when you use that approach, it’s a process improvement methodology where you’re going to the sharp end, you’re engaging the people closest to the problem and you’re asking them what is the thing that would make this faster, more simple, and make doing the right thing the path of least resistance. When you can engage them in that work and get them thinking about how to do it, what you do is you create an army of problem solvers. And as leaders, that’s our goal.
Kandice: Have you ever read the book Multipliers? It’s great. Liz Wiseman. It’s about how people do this, how they become these kinds of leaders. And she talks about accidental diminishers — like we’re all trying to do the right thing, but you’re really hitting on a lot of the qualities of not only just taking your talent, but multiplying that around you. And actually something we’ve been talking a lot about is multiplying organizations. How do you create an environment where the multiplying behavior is the easiest behavior? And it really does sound like that is the kind of leader that you are.
Angela: And I wanted to touch on one thing you said, because I think early in leadership, everyone goes through the moment where they think that they need to have all of the answers and they think that is what makes a good leader. And it kind of is a slow trickle evolution in leadership for you to realize, you know what, you might have some of the answers in your head. But saying those is gonna diminish the quality of the team coming to that and the team coming together to solve that challenge and then them taking that ownership. So I think maturity in leadership is knowing when to let the team come forward, when to listen, when to motivate somebody else and lift somebody else up.
I think there’s one more that you talked about that I would love to learn more about. You expanded into maternal health with an IRB approved study. Tell us a little bit about that and what that passion project was about.
Josh: So building on the success of our diabetes food pharmacy initiative, we were able to leverage those outcomes and go back to some of the payers that we worked with to try to see if we could get additional funding. While we weren’t successful, we knew that we had data, we had a story, and we had something that could help us to focus on a new patient population where we might be able to get more buy-in.
And so we were talking about the Black maternal health crisis and how Black birthing people have different outcomes in their pregnancy because of so many different factors in our healthcare system. And so what we did is we tailored a food as medicine program to focus on patients in pregnancy with hypertension, diabetes, or obesity.
And so we created a proposal using some of our past outcomes and identifying what program would impact this population and how we could leverage different tools like medically tailored meals and nutritionist support. And once again, we went to our foundation and we said we’re looking to find a donor that’s interested in these types of projects and this is what we’re proposing.
Very quickly we latched on — somebody latched on to this concept and offered us a considerable amount of money to go and do the work that we needed to do. And so we were able to develop an IRB approved study, a randomized control trial, enrolling 84 patients in a food as medicine initiative. And we’re just completing our last patient in our study and are going to — I’m really optimistic about what the data’s gonna show and how we can really take the next step to get more support.
So I think it’s really discouraging sometimes to be told no, but I think we can oftentimes use these things as steps in our process to continue to make an impact. And that’s really how we’re looking at this.
Angela: Payers said no to funding something? That’s so shocking. Not shocking for anybody here. That is amazing. I’m so excited to hear the results of that program and how that goes. I wish I could multiply you across every health system in America because we need more of this innovation, thinking about problems, thinking about the root cause. And I feel like healthcare has gotten stuck thinking about things in a box. And that is not how people live. They live outside of the box. And that is where the problems exist.
Kandice, do you have any closing questions for Josh?
Kandice: Yeah, well, I think that there’s so much leadership wisdom in there. If we had — let’s say you’re coaching your best friend’s son or daughter, and they ask you what is the most important skill that they can work on to be a successful leader in the next decade, what do you tell them?
Josh: You know, you’re gonna laugh, but I heard Shonda Rhimes giving a graduation speech and somebody asked her how she does it all as a mother and as a working person, how she manages to do everything so successfully. And her response was, I don’t. If I’m doing something well in one part of my life, I’m probably failing in another part of my life.
And I think that message as a high functioning person and an overachiever, I think that message really resonates with me as a leader. You know, as leaders, we can’t just accept failing at something. We can’t say, I’m gonna focus on this one thing and I’m gonna fail at all these other things. But I think when we wake up each day, we can choose to nurture the right things. And I think — am I nurturing the right projects today? I have a lot of balls in the air. I’m gonna be doing a lot of different things. I’m gonna maybe work on this one thing and then come back to it. But today, what is my greatest impact that I can make and what is the thing that I need to be focusing on?
And I think that’s what I try to do each day. I have an endless to-do list, it’s never gonna get done. The work will always be there. But I think our job as leaders is: are we doing the right thing? Are we nurturing the right project? Are we connecting with people? Today’s mission might just be to listen, to connect, and to engage with our teams, and that’s what’s going to create the lasting impact. We’ll always be able to come back to the checklist and the projects, but I think that’s my greatest advice is just think about what you’re putting your effort and your energy into today, make sure it’s the right thing, and just know that those other things will always still be there.
Angela: That’s phenomenal. That’s really great advice. I think that had you not spent so much time of your career building relationships, you probably wouldn’t be as successful at getting everybody around you to believe in something. So I can tell you’re spending your time in the right place.
Kandice: Well, thank you all so much. Thank you, Josh, for being here. It was such a pleasure speaking with you today.
Josh: Thank you so much. I had a great time.
Kandice: And thank you audience for joining us on Success and Chaos. Be sure to like, follow and share today’s episode on Spotify, Apple Podcasts, YouTube, or wherever you get your podcasts. And a special thank you to the Inflo Health team for their production support.
