Implementation Guide

Practice leadership incorporates health equity into quality improvement initiatives. (Related to BB1 – Engaged Leadership)

Action Items:

Health equity is considered and included in practice AIM statements and goals.

Considerations to measure elements of health equity are included in PDSA cycles.

Rationale:

For health equity initiatives to be successfully adopted and maintained by clinical teams, leadership must clearly communicate to patients, staff, and providers that health equity is a fundamental value and a strategic priority. This communication must also be supported by meaningful action towards identifying and closing health inequities within the patient population. QI initiatives may inadvertently worsen health inequities by employing strategies that are targeted towards or more easily accessible to patients with more resources or advantages at baseline. By explicitly setting equity goals and measuring outcomes among differently advantaged populations, practices can avoid these unintended consequences.

Resources:

Practice develops and implements a process to routinely gather and update patient demographic information, including race, ethnicity, language, sexual orientation, gender identity, and disability status. (Related to BB2 – Data Driven Quality Improvement)

Action Items:

Practice identifies fields in Electronic Health Record (EHR) where patient demographics including race, ethnicity, language, sexual orientation, gender identity, and disability status can be captured.

If the practice cannot identify these fields in the EHR currently, then the practice explores options for creating the ability to capture this data moving forward.

Practice develops a standardized process to capture and/or update demographic data at each patient visit, including self-identification, when making appointments and through patient portal check in.

Rationale:

To describe and evaluate health disparities, a practice first needs to recognize and document the various dimensions of diversity of the patients they serve (e.g., race, ethnicity, gender identity). Regularly and routinely gathering patient demographic information help practices identify and address differences in care delivered for specific patient populations, distinguish which populations do not achieve optimal results from interventions, assess whether the practice is delivering culturally responsive care, and develop additional patient-centered services. For example, chronic conditions can be overwhelmingly prevalent and result in worse outcomes for specific populations, but this would go unnoticed without capture of accurate demographic data. Patient demographic information can help identify gaps in screening rates, which may result in updated point of care alerts for appropriate screenings. EHRs also support aggregation of population data to strategically track emerging “hot spots” and allocate health promotion resources in the disparate communities we serve.

Resources:

Practice includes consideration of patient demographics and health equity in quality improvement efforts. (Related to BB2 – Data Driven Quality Improvement)

Action Items:

Practice understands baseline capture rate of these patient demographics and uses that data to drive practice quality improvement work.

Practice stratifies performance on clinical quality measures by collected patient demographics to identify disparate outcomes if they exist.

If disparity by demographic category is identified, practice plans quality improvement work to address the disparity.

Practice explores the use of cost and utilization data to identify and address inequities across patient populations.

Rationale:

Social, economic, and environmental factors have resulted in patients systematically facing barriers to health based on race, ethnicity, gender identity, sexual orientation, language, age, and disability status. Capturing patient demographics accurately and consistently allows the practice to not only better understand their patient population overall health but provides the information necessary to support identifying disparate outcomes. Stratifying process and performance results by demographics sets the foundation for practices to identify and reduce health disparities. However, identification of disparities alone is not sufficient to achieve equity, which requires the added quality improvement steps of root cause analysis, goal setting and action planning to improve equitable care delivery.

Resources:

Advancing Health Equity. (2021, 01 01). Solving Disparities. Tools. Retrieved 06 03, 2021, from https://www.solvingdisparities.org/implement-change/tools

Cooper, L. A., Marsteller, J. A., Noronha, G. J., Flynn, S. J., Carson, K. A., Boonyasai, R. T., Anderson, C. A., Aboumatar, H. J., Roter, D. L., Dietz, K. B., Miller, E. R., 3rd, Prokopowicz, G. P., Dalcin, A. T., Charleston, J. B., Simmons, M., & Huizinga, M. M. (2013). A multi-level system quality improvement intervention to reduce racial disparities in hypertension care and control: study protocol. Implementation science: IS, 8, 60.

Halladay, J. R., Donahue, K. E., Hinderliter, A. L., Cummings, D. M., Cene, C. W., Miller, C. L., Garcia, B. A., Tillman, J., DeWalt, D., & Heart Healthy Lenoir Research Team (2013). The Heart Healthy Lenoir project--an intervention to reduce disparities in hypertension control: study protocol. BMC health services research, 13, 441.

Practice develops clear, holistic hiring processes that increase the diversity of team members. (Related to BB4 –Team-Based Care)

Action Items:

Practice leadership is proactive in seeking out and hiring clinicians and staff that reflect the diversity of the communities they serve.

Establish inclusive hiring practices, including required training for search committee members.

Create tools and resources to help better recruit, hire, and retain a more diverse workforce.

Rationale:

Research shows that ethnically and culturally diverse teams outperform their competitors along multiple dimensions. Holistic recruiting/hiring is a person-centered approach that focuses on the employee as a whole, not just their professional skill set, recognizing that their lived experiences and perspectives add value to team performance. Best practices include intentional outreach to attract a diverse pool of applicants, reviewing job descriptions for inclusive language, and setting evaluation criteria and standard interview questions before review. It is also important to include bias training for search committee members to mitigate bias during hiring process.

Attracting and retaining diverse talent can yield a workforce that is adept at innovation and creativity from the integration of fresh perspectives. It is also a socially conscious way to do business. Every time you recruit, it requires new thinking and questioning to ensure you are doing everything to attract the best candidates and allow them to succeed. While having a diverse team should absolutely be a goal of your organization, diversity doesn’t exist without inclusion. Inclusive workplaces are welcoming of all individuals and encourage equal engagement and representation to better support more groups of people, which leads to better outcomes for all.

“Diversity is being invited to the party; inclusion is being asked to dance.” – Verna Myers.

Resources:

Practice implements a team-based communication strategy to improve engagement of all team members. (Related to BB4 – Team-Based Care)

Action Items:

Practice leadership engages staff in change management and decision making.

Leadership fosters a culture of inclusion where all staff members feel safe to contribute and participate in team discussions.

Practice leadership, staff, and clinicians develop mutually agreed upon ground rules or best practices for group meetings, which may include having staff speak first, avoiding interruptions, etc.

Rationale:

In addition to the power difference based on professional roles and socioeconomic status across roles in primary care, in many practices’ clinic staff are often people of color or from marginalized backgrounds, while physicians and other providers are often from more advantaged groups. Developing communication strategies that foster bidirectional communication between leadership and staff at all levels will help empower all personnel to contribute to the practice’s vision and operations, promoting team-based care.

Resources:

Practice develops and provides individualized professional development for all staff. (Related to BB4 – Team-Based Care)

Action Items:

Staff is asked to contribute ideas and topics for individualized professional development activities.

Leadership supports professional development opportunities that meet the individual needs of staff members.

Leadership assesses the need for practice-wide diversity, equity and inclusion training and seeks out opportunities to support identified training needs.

Rationale:

Including members of the team in the identification of their development goals leads to increased ownership of the goals and greater likelihood of achievement. Self-defined professional development increases team-members' sense that they are important to the team and have a valuable role in the delivery of high-quality, culturally responsive patient care. Retaining team members fortifies continuity of relationship between patients and the care team and increases patient satisfaction in their experience of care. Patient satisfaction and comfort with the care team is key to building trust, which also helps balance power between the patient and care team, and potentially lowering barriers in communication.

Practice recruits and retains members of the Patient Family Advisory Council (PFAC) that represent the diversity of the population served. (Related to BB5 – Patient and Family Engagement)

Action Items:

Practice proactively supports PFAC activities that make it possible for representatives to participate (after hours, childcare provided, etc.).

Practice is intentional about acting upon recommendations arising from diverse PFAC.

Rationale:

In the past and present, certain communities have been marginalized when providers and decision-makers do not consider or seek time to understand the perspectives and experiences of those who will be impacted. Practices must work in ways that honor community experience and encourage increased community involvement as partners in healthcare. Ideally, community engagement should be integrated into all aspects of health design, planning, governance, and delivery. Whenever possible, strategies for community engagement should center on the needs of patients and community. PFAC meetings and interactions should be led in such a way that each person participating has a voice and feels that suggestions are being heard and considered.

Resources:

Practice assesses the inclusivity of the practice through items on their patient experience survey. (Related to BB5 – Patient and Family Engagement)

Action Items:

Annual patient experience survey includes questions that assess inclusivity.

Practice is intentional about acting upon recommendations arising from patient experience survey.

Rationale:

Asking patients directly for their feedback and insight can add another dimension to the practice’s understanding of inclusivity and equity. Some elements of questions in patient satisfaction surveys that may help you assess inclusivity in your practice may include:

My provider explained things in a way that was easy to understand

My provider listened carefully

My provider showed respect for what I (the patient) had to say

My provider asked if there are things that make it hard for me (the patient) to take care of their health

My provider treated me (the patient) with courtesy and respect

My provider avoided making assumptions about me (the patient) or my health

While these assessments are anonymous, you may identify disparities in patient experience by including some demographic questions within the patient satisfaction tool. Looking at the results stratified by those demographic groups and planning improvement activities with that information will help to improve quality of care and patient experience of care over time.

The practice identifies and addresses equity issues impacting patient access to care, including telehealth services. (Related to Telehealth and BB8 - Access)

Action Items:

Practice undertakes a comprehensive, critical examination of policies to identify clinic policies and procedures that create avoidable barriers to care. Examples include late and no-show policies.

Practice undergoes a process to prioritize which problematic policies will be changed and eliminates or adapts those policies.

Practice explores feasibility of expanded access through evening and weekend hours.

The practice identifies needs of patients not able to access telehealth services and develops an appropriate intervention.

Rationale:

Organizational policies, procedures, and structures are created by clinical leadership teams, a group that typically benefits from sufficient resources, power, and ability to access and manage their own healthcare with few challenges. In contrast, patients often face many barriers to engaging fully with the healthcare system. A non-exhaustive list of such barriers includes lack of time off from work to attend appointments, reliance on public transportation, lack of reliable internet access, physical or mental disabilities, or implicit biases of healthcare professionals. Practice leadership may be unaware of how these factors impact the health and wellbeing of their patients, so a deliberate search for avoidable barriers to care is necessary to minimize the practice’s own contributions to health inequities. When specifically considering telehealth, certain populations have greater challenges to accessing the necessary technology and resources. These populations include those with limited health or technology literacy, rural residents, racial/ethnic minorities, older adults, and those with limited English proficiency. Without efforts to include all segments of the practice population in telehealth initiatives, health disparities may emerge or worsen.

Resources:

BB1.1.1 – Practice leadership sets practice-wide expectation for evaluating and improving clinical and operational processes and outcome.

Action Items

Leadership has a plan that has been communicated to staff (either verbally or in writing).

Practice has a way to monitor and evaluate processes and outcomes.

Practice Facilitator Methodology:
Confirm the communication to practice staff and that there is a process in place for evaluating changes.

BB1.2.1. Practice leadership allocates appropriate resources (including time for appropriate QI team membership) to ensure continuous quality improvement.

Action Items:

Determine the time and space requirements for ongoing QI meetings. Protect time for QI team meetings by blocking patient care responsibilities where necessary.
Consider what time and resources may be required for QI team work outside of regular meetings and budget for anticipated expenses.

Practice Facilitator Methodology:
Confirm and document ongoing, regular QI team meetings are occurring. Confirm the practice has allocated sufficient resources for the QI work, including engagement of adequate practice site clinicians and staff in the process.

BB1.3.1. Practice leadership develops and implements a process to recognize and reward clinic level quality improvement initiatives.

Action Items:

Practice has developed QI capability within the practice and empowers staff/providers to participate in QI Activities.
QI within defined job duties, recognizing and rewarding innovation and improvement.

Practice Facilitator Methodology:
Confirm recognition and rewards are being considered in the clinic.

BB2.1.1. Practice develops quality improvement (QI) team and meets monthly.

Action Items:

Form a QI team with key staff members from each area of the practice.
Provide training on QI methods and tools for all involved staff.
Define responsibilities of each team member and identify a clinical champion. Include who will be responsible for validation, production, review, and communication of metrics.
Schedule regular team meetings focusing on QI projects within the practice.
Utilize practice assessment tool (Milestone Attestation Checklist) to assist the practice in determining their starting point and prioritizing processes for QI work.

Practice Facilitator Methodology:
Confirm and document improvement team meetings in monthly field notes

BB2.1.2. Practice sets quality metric goals using benchmarks and reviews performance on internally validated CQMs at least quarterly.

Action Items:

1. Review performance on CQMs and compares it to benchmarks (at least quarterly, but ideally monthly).
2. Review utilization data and is actively trying to improve or sustain progress.

Practice Facilitator Methodology:
Confirm and document practice using CQM data in QI efforts.

BB2.2.1. Practice develops processes for providing performance feedback to providers at least quarterly, including CQM, cost and utilization data.

Action Items:

Review reporting requirements for any health plan programs in which your practice participates.
Select which data (including CQM, cost and/or utilization data) will be used for performance feedback, and develop strategy for how this will be presented to providers.
Share QI data with all clinic staff via clinic-wide meetings or displays in a central area.

Practice Facilitator Methodology:

Confirm that performance feedback is provided to providers.

BB2.2.2. Practice uses organized QI approach to meet quality measure goal/benchmark for at least one CQM.

Action Items:

Set a goal for how often you will complete PDSA cycles on CQMs; revisit this goal in QI team meetings at least annually.
Use PDSA cycle to support continuous quality improvement.

Practice Facilitator Methodology:

Confirm and document practice data driven QI efforts.

BB2.3.1. Practice evaluates its quality improvement process including clinician and staff engagement and the improvements attained and implemented.

Action Items:

Incorporate regular improvement methodology to execute change ideas in the practice setting.
Empower staff/providers to participate in QI activities by allocating time for QI activities, including QI within defined job duties.

Practice Facilitator Methodology:

Confirm and document that the practice is using QI to implement improvements.

BB2.3.2. Practice meets quality measure goal/benchmark for at least three CQMs.

Action Items:

Review data, including CQM data you submitted to ISP, at QI meetings.
Develop and document a Plan-Do-Study-Act (PDSA) for rapid cycle improvement.

Practice Facilitator Methodology:

Confirm practice implementation of protocols and workflows related to three chosen quality measures.

BB3.1.1. Practice designs and implements process for validating primary care provider and/or care team assignments with patients.

Action Items:

Confirm empanelment assignments with providers and patients.
Develop a plan for empanelment of new patients.
Monitor extent of empanelment through EHR or other reports to determine percentage of patients empaneled.

Practice Facilitator Methodology:
Confirm practice has implemented a process of assigning patients to PCPs/care teams.

BB3.2.1. Practice has assessed patient panel and assigned primary care providers and/or care teams to 90% of patient population.

Action Items:

Run reports regularly (i.e., quarterly) to determine empanelment status. Update empaneled patients as necessary to rebalance provider/care team panels and assign un-empaneled patients.

Practice Facilitator Methodology:
Confirm empanelment of 90% of patients.

BB3.2.2. Practice reviews and attempts to reconcile payer attribution list on a quarterly basis.

Action Items:

Review payer(s) methodologies for distribution of attribution reports and their methodology for reconciling discrepancies.
Review attribution reports and lists of patients and compare against empanelment panels within one week of receipt.
Practice actively follows payer(s) methodologies within one month of receipt of attribution lists to reconcile any discrepancies.
Monitor concordance between internal empaneled patients and payer attribution reports.

Practice Facilitator Methodology:

Confirm review and reconciliation of payer attribution lists.

BB3.3.1. Practice actively manages acceptance of new patients based on chosen panel size to optimize access continuity and business.

Action Items:

Ensure non-active patients are removed and new patients are assigned.
Utilize EHR to assign roles to practitioners and care teams.
Use patient panel report by practitioner and/or care team to help you determine which practitioner can accept new patients.

Practice Facilitator Methodology:

Confirm practice is able to manage panels and optimize patient needs.

BB4.1.1. Practice develops written job descriptions, including clear roles and responsibilities.

Action Items:

Develop clear roles and responsibilities for each team member and put these in writing with a policy and procedure that outlines the process and decisions made.
Develop a plan for when staff turnover occurs to ensure tasks continue to be done as planned.

Practice Facilitator Attestation Methodology:
Confirm review of at least two job descriptions. Practice can attest that others are in place.

BB4.1.2. Practice identifies and implements a team-based care strategy to improve communication (team huddle, debriefs, collaborative care planning).

Action Items:

Examples may include:

Daily Team Huddles
- Create a template agenda for daily huddles that includes the topics that will be discussed each day. Huddles may include time to:
  1. Prospectively plan for patients who can benefit from pre-visit activities (e.g., point of care tests, immunizations, paperwork) and extra time and assistance.
  2. Communicate and prepare for staff, provider, or equipment changes.
- Adjust huddle timing, participants, and agenda as needed to best align the team at the start of a clinic session, build team culture, and improve communication for a more engaged workforce.
Collaborative Care Planning Sessions
- Implement a regularly scheduled collaborative care planning session with the practice team to discuss the overall care of selected population of empaneled patients.
- Include a varied group of relevant team members such as providers, patients and families, nurses, medical assistants, care coordinators, behavioral health specialists, clinical pharmacists, and psychiatrists.
- Adopt consistent strategy and expectations for conducting care planning sessions that will keep the team efficiently moving through the review of multiple patients. Examples may include an agenda or a shared template for preparation and review.

Practice Facilitator Methodology:
Confirm practice implementation of team-based care strategies.

BB4.1.3. Practice assesses teamwork and team experiences using a standardized tool, reviews results and prioritizes area(s) for improvement.

Action Items

Complete a practice assessment of the distribution of patient care tasks by role to measure how practice teams are functioning.

Practice Facilitator Methodology:
Confirm review of the standardized tool with the practice or practice's quality improvement team.

BB4.2.1. Practice reviews roles and responsibilities for team-based care activities to ensure accountability for assigned tasks.

Action Items:

Build a culture that supports teamwork that will empower staff to take on new roles, act independently, and communicate effectively.
Identify the leader(s) of each practice team.
Establish and provide organizational support for the teams, including protected time for teams to interact and plan their activities.
Distribute the workload throughout the team to make optimal use of each member training and skill set, having members work at the top of their license to the extent possible.
Develop training for team members on new skills.
Help patients understand what they can expect from the team-based care model through pamphlets, phone scripts, in-person conversations, and other means of communication.

Practice Facilitator Methodology:

Confirm implementation and/or maintenance of team-based care model.

BB4.2.2. Practice identifies and implements two team-based care strategies to improve communication (team huddle, debriefs, collaborative care planning).

Action Items:

Building from Milestone 4.1.2, continue with additional team-based care strategies.

Practice Facilitator Methodology:

Confirm practice implementation of team-based care strategies.

BB4.2.3. Practice uses QI team to develop and implement a plan for improving prioritized area(s).

Action Items:

Integrate QI methodology into daily work
Train staff and utilize the entire team for QI work.

Practice Facilitator Methodology:
Confirm practice is implementing QI into daily practices.

BB4.2.4. Practice develops and provides comprehensive orientation and onboarding support to all new staff and ongoing professional development for all staff.

Action Items:

Build QI into job duties and job descriptions.
Create an onboarding process that trains new staff on their role in the QI process. All staff should have a role.
Provide at least yearly professional development related to QI process

Practice Facilitator Methodology:
Confirm practice is onboarding staff with an understanding their role in QI and providing professional development to sustain QI efforts.

BB4.3.1. Practice develops a system to recognize and reward team members for innovation, contributing to organizational goals and/or increasing their team-base care responsibilities.

Action Items:

Develop system for team members to contribute to improvement.
Reward staff for QI efforts. Options for rewarding staff may include:
- Paying for process improvement work
- Sharing in profits and/or performance-based incentive payment earnings where everyone on the team receives a percentage
- Awarding bonuses for meeting certain metrics
- Providing mon-revenue incentives to motivate your team, such as training and education to develop skills or obtain certifications
- Providing Flexible scheduling
- Offering work-from-home arrangements for certain tasks
- Providing staff lunches to recognize and celebrate successes on meeting goals
Consider PDSA cycles that encourage all staff to work at the top of their individual licensure.

Practice Facilitator Methodology:
Confirm practice has a system in place.

BB4.3.3. Practice re-assess teamwork and team experience and reviews trends to prioritize additional area(s) for improvement.

Action Items:

Evaluate and review team experience (at least annually).

Practice Facilitator Methodology:
Confirm practice reassesses team experience annually.

BB4.3.4. Practice institutes formal training or another process to improve the way its team works together, such as good communication, role clarity, respectful relationships, mutual trust, inclusivity and shared goals.

Action Items:

Define and document each team member’s roles and responsibilities, and assure that each team member works to the maximum of their skill set and credentials in order to optimize efficiency.
Provide ongoing professional development to support high functioning teams.

Practice Facilitator Methodology:
Confirm in QI team meetings that practice is functioning at top capacity.

BB5.1.1. Practice adopts at least one evidence-based decision aid or self-management support tool for a condition appropriate for their patient population.

*Preference-sensitive conditions are those which have treatment options that pose tradeoffs that the patient should consider with his/her physician when determining whether to proceed with treatment.

Action Items:

Educate care team members on the concepts of self-management support and available tools.
Choose preference-sensitive conditions that could be improved by providing self-management support resources. Conditions could include physical health or behavioral health concerns that result in high utilization, high cost, and/or lower satisfaction rates, or socio-demographic risk factors that contribute to poor utilization of preventative health services.

Examples could include: obesity in children or adults; diabetes in adults; depression care in children, adolescents, and/or adults (e.g., pregnancy-related depression); prematurity or other special health care need in infants; asthma care for children, adolescents, and/or adults; misuse of alcohol or marijuana.

Practice Facilitator Methodology:
Confirm the practice has chosen preference sensitive condition and document this in field notes, along with any changes or additions through the initiative.

BB5.1.2. Practice convenes a patient and family advisory council (PFAC) at least once and develops plans for how to integrate recommendations into care and quality improvement activities as appropriate.

Action Items:

Identify one or two practice champions to co-facilitate the advisory council.
Develop a recruitment plan (number of members, representative of practice population, supports/incentives for participation, length of service).
Recruit participants and secure commitments for engagement
Determine a governance structure including how agendas will be set, how feedback will be gathered and shared, and sphere of influence of the advisory council.

Practice Facilitator Methodology:

Confirm practice implementation of PFAC meetings.

BB5.1.3. Practice implements a patient experience survey and uses data to assess their delivery of primary care services as well as patient satisfaction with care.

Action Items:

Develop and administer a patient experience survey.
Ensure patients are directly involved and have the ability to direct care.
Communicate with patients and care givers about changes being implemented (by newsletter, signs in lobby or exam room, communication on hold music/message).
Regularly review and assess changes that are impacting care.

Practice Facilitator Methodology:

Confirm the use of patient experience survey and the Incorporation of results into practice.

BB5.2.1. Practice tracks use of their prioritized decision aid or self-management support tool and establishes a protocol and workflow to increase its use.

Action Items:

Once high-risk conditions are identified, select appropriate self-management tools and make these tools available to patients. For pediatric populations, self-management tools may target the parents or primary caregivers in addition to the child, if developmentally appropriate. Examples include:
- Asthma action plans that define green, yellow, and red indicators of asthma control and what to do for each level.
- for cholesterol management such as Mayo Clinic’s online aid for shared decision-making for cardiovascular prevention, medication options for depression.

Practice Facilitator Methodology:

Confirm practice implementation of decision aids or self-management tools.

BB5.2.2. Practice convenes a PFAC at least quarterly and integrates recommendations into care and quality improvement activities as appropriate.

Action Items:

Set quarterly meeting dates/locations in advance and on a . Adjust times, services, and locations to maximize participation from target patient advisors. For example, working adults may need to meet outside of normal business hours, and parents may be more engaged if they can bring their children and have on-site childcare. Snacks or meals could be offered depending on the timing of meetings.

Practice Facilitator Methodology:

Confirm practice implementation of quarterly PFAC meetings.

BB5.2.3. Practice reviews data from practice experience survey at least quarterly to identify areas for focus as part of their quality improvement process.

Action Items:

Implement patient experience survey.
Review data at least quarterly.
Identify areas of need to be part of quality improvement process.
Inform patients of focus/need areas and progress.

Practice Facilitator Methodology:

Confirm practice is using practice experience survey information in a meaningful way to inform QI.

BB5.3.1. Practice adopts at least two decision aids and/or self-management support tools, tracks their use and establishes protocols and workflows to increase their use.

Action Items:

Building on Milestone 5.2.1, adopt additional decision aids and/or self-management support tools.

Practice Facilitator Methodology:

Confirm practice implementation of at least two decision aids or self-management tools.

BB5.3.2. Practice establishes mechanisms to refresh PFAC membership when necessary and better integrates feedback into quality improvement activities.

See 5.1.2 and 5.2.2 for additional support on PFAC.

Action Items:

Periodically review the advisory council and adjust membership and processes to address patient experience more effectively. Particularly in the beginning, obtaining feedback for participants and making the necessary adjustments will increase the success and longevity of the council.

Practice Facilitator Methodology:

Confirm practice implementation of PFAC meetings. Periodically review membership and longevity on the board.

Encouraging Patients to Ask Questions: How to Overcome “White-Coat Silence”

Engaging Patients in Collaborative Care

Essential Steps of Shared Decision Making: Quick Reference Guide

Institute for Patient and Family Centered Care: Creating Advisory Councils

Nat'l Institute for Children's Health Quality PFAC toolkit

Patient and Family Advisory Council Getting Started Toolkit

BB6.1.1 Practice implements a risk stratification process for all empaneled patients, addressing medical need, behavioral diagnoses and health related social needs: Step 1: Use an algorithm based on defined diagnoses, claims or other electronic data allowing population-level stratification; AND Step 2: Add the care team’s perception of risk to adjust the risk stratification of patients, as needed.

Action Items:

Review available risk stratification methods with your QI team and care teams. Keep in mind the time and personnel costs needed to develop each method and how your practice would use the information to improve care processes for high risk patients and their families. Your Practice Facilitator can be helpful in identifying resources and information on various choices.
Decide on a risk stratification method.
Assign and empower at least one practice champion to coordinate the development, validation, training, communication, documentation, and monitoring aspects of the risk stratification method.
Tailor care management interventions to improve outcomes for the highest risk patients.

Practice Facilitator Methodology:
Confirm practice identification of a risk stratification methodology and that the practice has fully accomplished the milestone.

BB6.1.2. Practice identifies strategy to identify care gaps (e.g. EHR prompts, patient registry, data aggregation tool)

Action Items:

Engage the QI team to identify priority conditions to be tracked.
When making a new registry consider:
- The source of the data (e.g., EHR, claims, other population health registry).
- Patient diagnostic criteria (e.g., all depression or only depression on medications).
- The need for additional medication management and review (e.g., polypharmacy, frequent hospitalizations with changes to medications).
- The outcomes to be assessed. Those can be process outcomes (compliance with treatments, appointments), as well as health outcomes (improved objective measures).
Establish the timeline of the work, including when the patient cohort will be defined, who will do the data analysis, and when the outcomes will be assessed.

Practice Facilitator Methodology:

Confirm practice has identified strategy to address gaps in care.

BB6.2.1. Practice provides episodic and longitudinal care management to identified high risk population likely to benefit from intensive care management.

Action Items:

Based on previously selected strategy to identify care gaps (e.g., registry), contact patients who are not achieving pre-specified outcomes.
Engage care team members such as care managers, front desk staff and others in patient follow-up as needed.
Identify and test how patient care plans will be documented, including multiple members of the care team.

Practice Facilitator Methodology:

Confirm practice is proactively addressing care management through strategies to identify and care for high risk populations.

BB6.2.2. Practice implements workflow for improving proactive care gap management and tracks specific outcomes.

Action Items:

Engage with patients who have chronic diseases or known preventive gaps in care to close those gaps.
Work on improvement of outcome measures related to ISP.

Practice Facilitator Methodology:

Confirm the practice has implemented a workflow for care management and tracking outcomes.

BB6.3.1. Practice has documented care plan for 90% of its high-risk patients and families, with the care plans embedded in the EHR.

Action Items:

Identify important pieces of information that should be included in an individualized patient treatment plan, including physical and behavioral health goals. Create a template with appropriate headers or instructions for people to follow. Keep in mind care plans need to allow for a variety of types of patient goals, and components of the plans may be different for different populations (e.g., adults vs. children, patients seeing multiple specialists vs. healthy individuals). Include medication reconciliation in the creation and updating of care plans.
Train all care team members to create, access, and update care plans.
Set an initial goal for the number of care plans to be created within a certain amount of time. Consider starting with a subset of the practice’s empaneled patients to allow care teams to practice and provide feedback on the process.
Develop a process to update the care plans regularly to keep all team members up to date.

Practice Facilitator Methodology:

Review practice data and confirm target is met.

BB6.3.2. Practice assesses the impact of care gap management on outcomes and need for improvement in the process.

Action Items:

Build on previous work to assess outcomes from established registries and adjust clinical workflows and patient outreach efforts to show improvement in process and patient-centered outcomes.
Sustain active registries and consider focusing on new outcomes and/or new registry populations.

Practice Facilitator Methodology:

Tracking the care plan and the practice has fully accomplished the milestone.

BB7.1.1. Practice measures and reviews continuity of care for empaneled patients by primary care providers and/or care teams.

Action Items:

Discuss continuity of care at provider, staff and/or QI meetings so staff are familiar with the process and concept.
Practice is able to get a baseline report of continuity of care for empaneled patients.

Practice Facilitator Methodology:

Confirm practice has a continuity of care report or a report that can be used for continuity of care for empaneled patients.

BB7.2.1. Practice implements one strategy that improves continuity for practitioners and care team(s).

Action Items:

Set a reasonable goal using one tactic for continuity of care (the goal should not be 100% - right care at the right time vs provider relationship should be considered).
Verify staff and patients are benefiting from strategy.

Practice Facilitator Methodology:

Confirm practice has tried one strategy to improve continuity of care and document in field notes.

BB7.3.1. Practice re-assesses continuity of care and determines if further intervention is needed to improve continuity while balancing the need for prompt access to care.

Action Items:

Establish a system to review continuity of care.
Practice has a process to adjust empanelment process if necessary.

Practice Facilitator Methodology:

Confirm that practice has system in place and improving continuity of care.

BB8.1.1. Practice assesses access to primary care services for its patients through availability of appointments and through patient experience survey.

Action Items:

Create a baseline report of appointment availability.
Establish baseline from patient experience survey.

Practice Facilitator Methodology:

Confirm practice has a report for appointment availability and patient experience survey.

BB8.1.2. Practice representative with EHR access available 24 hours, 7 days per week that includes behavioral health information.

Action Items:

Develop a written protocol for providers to have access to patient health records that includes procedures for record sharing, reporting, documentation, scheduling.
Regularly share information with patients (verbally and in writing) about accessing after-hours services, particularly when they are new to the practice.
Information about accessing after-hours services should be posted at the practice, detailed on websites, and provided in initial patient paperwork.
Regularly review policies and procedures for contacting the practice when the practice is closed, including setting expectations about who will be responding to calls (e.g., a nurse triage line, an on-call provider who is not part of the practice, or the patient’s primary care provider). Be sure to include a process/procedures for responding to behavioral health urgent and emergent situations.
Consider developing processes for secondary triage to on-call response systems, access to clinical information, and next day scheduling systems

Practice Facilitator Methodology:

Confirm that patients have 24/7 access to practice representative with EHR access.

BB8.1.3. Practice assesses referral patterns and pathways and prioritizes high volume specialties with poor access for intervention.

Action Items:

Develop an effective referral management system
- Confirm that the referral is clinically necessary and appropriate
- Articulating a specific referral question or “ask”
- Effective patient clinical data is available to the specialist
- Defining and communicating the patient’s appointment responsibilities
- Ensuring that results of the specialty referral are received back to primary care
- Ensuring that specialty input resulting from the referral is documented and addressed

Practice Facilitator Methodology:

Confirm practice has referral sources and ability to evaluate and make changes.

BB8.2.1. Practice adopts extended hours, same day appointments, patient portal, or other methods to improve access and then re-assess for any problem areas.

Action Items:

Plans extended access services. This includes testing the financial sustainability of extended access.
Implement extended access services.

Practice Facilitator Methodology:

Confirm that practice has implemented and maintained at least one extended access service for patients.

BB8.2.3. Practice establishes collaborative agreements with specialty groups or adopts new technology (such as e-consults, virtual visits, ECHO) to improve patient access to specialty services.

Action Items:

If practice is establishing collaborative agreements:
- Define the types of referral, consultation, and co-management arrangements available
- Specify who is accountable for which processes and outcomes for care within the referral, consultation, or co-management arrangements
- Specify what clinical information should be provided, how the information is transferred, and timeliness expectations
If practice is adopting new technology:
- Create a process for practitioners to send a clinical question and relevant clinical information to the specialist, who responds by providing a clinical opinion and guidance and/or confirms the need for a face-to-face specialty appointment with the patient.

Practice Facilitator Methodology:

Confirm the practice has established a collaborative agreement with specialty groups that share in the care of their patients.

BB8.3.3. Practice assesses the impact of the collaborative agreements and/or new technology on patient access to specialty services and determines any next steps for further improvements.

Action Items:

Evaluate access to specialty care by tracking number of referrals, impact on patients, impact on staff and financial sustainability.

Practice Facilitator Methodology:

Confirm practice is reviewing specialty care access at least annually and seeking new collaborative care agreements with appropriate specialty partners.

BB9.1.1. Practice assesses the services it provides to its patients and identifies key services that could be added to improve comprehensiveness of care, including for behavioral health.

Action Items:

Measure the current services provided to patients.
Identify services that need to be improved or added. This could be done by surveying patients, staff feedback, community feedback, patient and family advisory council (PFAC) or focus groups.
Prioritize and evaluate the added services, including financial sustainability.
Plan for meeting the behavioral health needs of patients, either through integration or intentional partnership with community behavioral health resources.

Practice Facilitator Methodology:

Confirm practice has a completed an assessment of services and a plan has been established.

BB9.1.2. Practice develops a vision for behavioral health integration and chooses a strategy (such as full integration, virtual integration, collaborative care model) to improve comprehensiveness of behavioral health services.

Action Items:

Complete the practice assessment activities to understand where your practice currently stands related to the levels of behavioral health integration and prioritize next steps in addressing your patients’ behavioral health needs.
Identify the level of BH integration that the practice aspires to achieve according to SAMHSA and levels of Collaboration/Integration (Coordinated, Co-Located, or Integrated).
Identify scope of practice/population needs, organizational supports, FTE needs, electronic health record sharing needs, and supervision needs to accomplish level of integration desired.
Create a written, signed vision statement including how your practice will approach BH integration.

Practice Facilitator Methodology:

Confirm that a vision statement exists that includes their planned pathway for behavioral health transformation. This should be documented and shared across the practice and with the PF/RHC.

BB9.1.3. Practice develops a plan to systematically measure and track patient’s behavioral health outcomes related to at least one of the following conditions: depression, obesity or substance use disorder.

Action Items:

Determine which data source(s) will provide the best data to guide improvement. Choose a small number (2-4) of those reports to start with that are readily available, easily updated, align with clinic improvement priorities, can show change in 3-6 months, and measure processes or outcomes important to patient health and experience.
Review data at QI meetings.
Develop and document a Plan-Do-Study-Act (PDSA) for rapid cycle improvement.

Practice Facilitator Methodology:

Confirm practice using data to improve behavioral health outcomes.

BB9.1.4. Practice performs assessment of referral pathways and available after-hours support for behavioral health working with RHCs when possible.

Action Items:

Identify policies and procedures on how crisis intervention, urgent care, and emergent care episodes are handled between physical health and behavioral health providers, whether they are in different sites, co-located, or can be accessed with a warm hand-off.
Determine how referrals are made and which patients are referred.
Compile a resource list or spreadsheet of behavioral health providers approved or in-network for the commercial and public plans involved in the SIM initiative. Prioritize behavioral health centers and providers that accept the common payers seen in your practice and those locations open to new patients. Identify behavioral health providers that specialize in working with certain populations (e.g., pediatrics, families, early childhood, substance abuse and dependence) and denote specializations in the resource lists. Information may include hours of operation, procedures for obtaining initial appointments, necessary paperwork, etc. Preliminary lists may be found on company websites and may be added to using experience and word of mouth. For Behavioral Health Providers under Medicaid, a list of Community Mental Health Centers (CMHCs) can be found by contacting the Medicaid office, or by performing searches by county. Regional Health Connectors can assist practices with this information gathering and relationship building.
Review and update this list regularly to ensure accuracy. Assign someone in the practice to keep this resource up to date.

Practice Facilitator Methodology:

Confirm practice has performed assessment and has contacted RHC.

BB9.1.5. Practice identifies data sources and technology needed for bi-directional data sharing with facilities responsible for the majority of their patients’ hospitalizations and ED visits.

Action Items:

Determine if and how the practice is receiving hospital admission and discharge notification where patients are accessing care.
Determine who will be responsible for contacting patients after hospitalization or ED visit, such as a care manager, clinic nurse, or patient navigator.
Develop a written policy that describes practice plan for following up with patient’s post-discharge from the hospital or ED.
Create flexibility in provider schedules to allow for ease of scheduling follow up appointments within 72 hours or one week (as appropriate) after ED visit or hospitalization. This may include blocking a specific number of appointments for this explicit purpose or blocking appointments for urgent needs that can only be scheduled within the preceding 72 hours.

Practice Facilitator Methodology:

Confirm practice implementation of policies and procedures for transitions of care for hospitalization and ED visits and that the practice has fully accomplished the milestone in the PF opinion.

BB9.1.6. Practice establishes a collaborative agreement with at least one behavioral health group or other high cost and/or high-volume specialty group.

Action Items:

Review templates for creating a .
Determine a beneficial high cost/high volume specialty group with whom to develop a care compact based on the needs of your practice and patient panel.
Have a medical director or other clinic leader reach out to these specialty providers to gauge interest in care compact agreements.
Work collaboratively with partners to create mutually beneficial care compact.
Ensure care team can articulate how to use agreements.

Practice Facilitator Methodology:

Confirm practice has at least one collaborative care agreement with high cost/high volume specialty provider.

BB9.2.1. Practice assesses the impact of any added services on quality and/or cost of care.

Action Items:

Run reports from EHR or by surveying patients, asking for staff feedback, community feedback, patient and family advisory council (PFAC) or focus group on any changes that have been made in the clinic.
Review data from payers or claims data around cost of care to monitor change over time.

Practice Facilitator Methodology:

Confirm the practice has assessed changes in the clinic.

BB9.2.2. Depending on chosen strategy, practice 1) hires and onboards or contracts for an onsite behavioral health professional, 2) contracts with virtual behavioral health services, 3) contracts for collaborative care model supports, or 4) otherwise arranges for engaging the appropriate behavioral health workforce.

Actions Items:

Onsite behavioral health:
- Incorporate appropriately trained and licensed staff into the primary care team to provide evidence-based behavioral health treatments and time-limited therapy.
- Ensure staff are trained and workflows are in place for warm handoffs.
Virtual behavioral health services:
- Ensure agreement is in place for virtual behavioral health services
- Ensure staff are trained and workflows are in place for virtual visits
Collaborative care model:
- Establish agreement for behavioral health services to be provided.
- Ensure staff are trained and workflows are in place for virtual visits.
Arrange for appropriate behavioral health:
- Identify community resources for behavioral health referral. Practice has agreement in place.
- Ensure staff are trained and workflows are in place for appropriate visits.

Practice Facilitator Methodology:
Confirm availability of behavioral health services to patients.

BB9.2.3. Practice systematically measures and tracks patient behavioral health outcomes related to at least one of the following conditions: depression, obesity or substance use disorder.

Action Items:

Implement the plan from 9.1.3 by having your designated practice champion pull the appropriate reports at predetermined intervals on your behavioral health outcomes of interest.
Incorporate evaluation of these data points into your QI team meetings.
Provide data feedback on these outcomes to providers along with CQMs, and cost and utilization data.

Practice Facilitator Methodology:

Confirm presence of tracking data and using data to improve BH outcomes.

BB9.2.4. Practice establishes a collaborative agreement with at least one community behavioral health provider.

Action Items:

Review templates for creating a .
Determine a beneficial BH practice with whom to develop a care compact based on the needs of your practice and patient panel. For many practices, including those with an integrated behavioral provider, this could include a Mental Health Center, a psychiatry practice or another provider of specialty behavioral health care.
Have a medical director or other clinic leader reach out to these BH providers to gauge interest in care compact agreements.
Work collaboratively with partners to create mutually beneficial care compact.
Ensure care team can articulate how to use agreements.

Practice Facilitator Methodology:
Confirm the development of at least one collaborative agreement with at least one community behavioral health provider.

BB9.2.5. Practice implements a process to contract at least 75% of patients who are hospitalized in target hospital(s) within three business days after discharge, including medication reconciliation.

Action Items:

Implement policy that describes practice plan for following up with patient’s post-discharge from a targeted hospital. Follow-up could include phone call, office visit or another encounter as appropriate.
Track the numerator and denominator of patients hospitalized and seen in the ED to ensure at least 75% of patients are contacted.
Prioritize contacting patients for medication reconciliation and determination of follow up needs for those with chronic conditions or frequent hospital
Include in the medication reconciliation process ascertainment of patient self-reports of medication adherence, including issues of side effects, forgotten doses, and financial costs. For patients with low adherence, pill counts can be selectively used for critical meds. If appropriate and with patient consent, engage family members and caregivers in medication adherence discussions.

Practice Facilitator Methodology:

Review practice data regarding contact of patients after hospitalization or ED visit and that at least 75% of patients are contacted within 3 days of hospitalization or ED visit.

BB9.2.6, Practice develops collaborative care agreements with at least two other high cost and/or high-volume specialty groups.

Action Items:

Build upon progress from milestone 9.1.6 to establish collaborative care agreements with additional high cost/high volume specialty groups.
Define the types of referral, consultation, and co-management arrangements available.
Specify who is accountable for which processes and outcomes of care within the referral, consultation, or co-management arrangements.
Specify what clinical information should be provided, as well as how the information is transferred and the expected timeliness of the information

Practice Facilitator Methodology:

Confirm practice has at least two collaborative care agreements.

BB9.3.2. Practice implements protocols for identification and care management for high risk behavioral health populations.

Action Items:

Review the risk stratification process, track the proportion of the clinic’s patients in each category, adjust implementation plans, and link the risk categories to care management strategies in the clinic.
Identify important pieces of information that should be included in an individualized patient treatment plan, including physical and behavioral health goals. Create a template with appropriate headers or instructions for people to follow. Keep in mind care plans need to allow for a variety of types of patient goals, and components of  the plans may be different for different populations (e.g., adults vs.  children, patients seeing multiple specialists vs. healthy individuals). Include medication reconciliation in the creation and updating of care plans.
Train all care team members to create, access, and update care plans
Based on previously selected strategy to identify care gaps (e.g., registry), contact patients who are not  achieving pre-specified outcomes.
Build on previous work to assess outcomes from the registries and adjust clinical workflows and patient outreach  efforts to show improvement in process and patient-centered outcomes.

Practice Facilitator Methodology:

Confirm practice implementation of protocols.

BB9.3.3. Practice implements a plan to systemically measure and track patient behavioral health outcomes related to a second of the following conditions: depression, obesity or substance use disorder.

Action Items:

Build upon progress from 9.1.3 to track additional behavioral health outcome measures.

Practice Facilitator Methodology:
Confirm practice using data to improve behavioral health outcomes.

BB9.3.4. Practice develops and implements process for bi-directional data sharing with at least one community behavioral health provider.

Action Items:

Develop a process for data sharing for patients known to be under the care of outside behavioral health providers, such as through the use of EHR template letters containing clinic notes that can be automatically faxed or mailed to the behavioral health provider (or primary care provider in the case of CHMCs) after completion of the note.
Plan protocols for how received records will be delivered, to whom they will be delivered, and how they will be reviewed (i.e., expectation of timeliness, if/where outside records can be scanned into the EHR, if it is appropriate to make other documentation or summarize outside information elsewhere in the patient’s chart).

Practice Facilitator Methodology:
Confirm a plan for bidirectional data sharing completed with at least one behavioral health provider.

BB9.3.5. Practice implements a process to contact at least 75% of patients with ED visits within three business days.

Action Items:

Implement policy that describes practice plan for following up with patient’s post-discharge from ED. Follow-up could include phone call, office visit or another encounter as appropriate.
Track the numerator and denominator of patients hospitalized and seen in the ED to ensure at least 75% of patients are contacted.
Prioritize contacting patients for medication reconciliation and determination of follow up needs for those with chronic conditions or frequent ED utilization.

Practice Facilitator Methodology:

Review practice data regarding contact of patients after ED visit and that at least 75% of patients are contacted within 3 days of ED visit.

BB9.3.6. Practice assesses the impact of the collaborative care agreements on access, coordination of care and/or cost of care and determines need for revision of existing agreements and/or development of new agreements.

Action Items:

Review collaborative care agreements at least annually.
Determines if changes need to be made to existing collaborative care agreements.
Evaluate if new collaborative care agreements need to be made.

Practice Facilitator Methodology:

Confirm annual review has been completed and practice can and will make changes if necessary.

Care Collaborative Agreement Facilitation Guide

Coordinating Care in the Medical Neighborhood Critical Components and Available Mechanisms

Financially Sustaining Behavioral Health Integration

PCPCC �鶹��ý�� Primary Care Specialty Care Compact

Practical Approaches for Achieving Integrated BH Care in PC Settings

SAMSHA Standard Framework for Levels of Integrated Care

BB10.1.1. Practice considers mechanisms to maximize benefit of participation in alternative and performance payment arrangements.

Action Items:

Practice has systematically streamlined processes and has eliminated waste.
Practice is using an organized approach to reviewing processes.
Practice understands the value of each process and the value it brings to patients, payers and staff.
Practice understands APM and how they function

Practice Facilitator Methodology:

Confirms a practice can articulate understanding of APM models

Practice can demonstrate and articulate its value

Practice can point to areas of waste and removal of such waste

BB10.1.2. Practice identifies available cost of care reports that they can use to identify and manage high cost areas.

Action Items:

Practice has payer level reports that they can use to evaluate costs to patients and payers.
Some example of where to get reports:
- Medicare – QPP reports
- Medicaid – APM reports
- Insurance company reports
- CPC+ reports

Practice Facilitator Methodology:

Confirms the practice has a report available for cost of care.

PF can assist practice obtain TCOC data from payers if available

BB10.1.3. Practice completes an annual budget that includes revenue and planned expenses for value-based revenue.

Practice completes an annual budget that includes revenue and planned expenses for value-based revenue.

Change in practice requires a reflective, action-oriented team to remain focused on established improvement goals. Formal clinical and administrative leaders as well as informal leaders from front and back office should meet regularly to inform tests of change and be responsive to practice level financial data.

Action Items:

Practice completes an annual budget that includes revenue and planned expenses for value-based revenue.
Practice monitors an adjusts budget for value-based revenues and expenses as needed.
Practice shares financial data transparently with staff and providers and develops their capabilities in understanding the organizations finances and in using business practices and tools.

Best practice: Create and maintain a budget

Creating and maintaining a practice budget can bring extra discipline to your business habits, resulting in a healthier practice with fewer problems. A budget can anticipate potential problems i.e., cash shortages and prepare for them.

Action Items for Best Practice:

Practice works with PF to list all the products and services the practice supports, bills or does not bill, on or off site.
Practice management system/biller coder has data on volume of visits, codes, billing and collected revenue.
Practice calculates the cost per visit base on the E&M and or CPT code for procedures.
PF may need to assist practices obtain fee schedules and work with practice management system to be sure fee schedules are loaded for reach contract and reviewed for correct payment.
Review and analyze budgets monthly, or at least quarterly.

Practice Facilitator Methodology:
Confirm and document improvement team meetings in monthly field notes that the practice has a budget as identified in learning Plan ISP Budgets.

BB10.2.1. Practice evaluates impact of value-based payment agreements on financial stability of practice, quality of care provided and/or clinician and staff satisfaction.

Action Item:

Develop a plan to use value-based payment agreements to improve care, reduce costs, and improve satisfaction. When using additional revenues (i.e., to hire new staff, purchase new equipment, protect time for practice improvement activities), consider how to make these changes sustainable long-term, regardless of payment models available.

Practice Facilitator Methodology:
Confirm practice development and implementation of a plan. Demonstrate how the practice uses and assesses the impact of value-based payments. Document if barriers have prevented value-based payment agreements from being developed.

BB10.2.2. Practice incorporates management of cost of care into their quality improvement process, including selecting strategies to reduce costs.

Action Items:

Practice identifies available cost of care and quality outcomes reports.
Use reports to identify and manage high cost areas and quality improvements.

Practice Facilitator Methodology:

Confirm practice use of cost and utilization tools. identify the cost of care for all patients and for those with at least one specific behavioral health condition. Document use of this data in improvement team minutes.

BB10.2.3. Practice monitors and adjusts budget for value-based revenue as necessary.

Action Items:

Practice has an active budget (from 10.1.3).
Practice is able to adjust budget as necessary for changes and for value-based revenue.
Practice is able to complete return on investment (ROI) for changes they would like to make.

Practice Facilitator Methodology:

Practice can articulate what items in the budget need to be adjusted up or down for VB contracts

BB10.3.1. Practice develops value proposition and uses it to engage payers in value-based payment discussions.

Action Items:

Practice engages entire team in developing value proposition.
Practice writes and completes research within the value proposition.
Practice engages payers in negotiations using value proposition.

Practice Facilitator Methodology:

Confirms practice has a vetted value proposition that has been used in payer negotiation meetings.

BB10.3.2. Practice demonstrates improvement on at one cost or utilization metric.

Action Items:

Practice has a way to measure cost of care (from 10.1.2).
Practice has utilization reports from CMS or other payers
Practice has a way to measure utilization or cost without waiting a year for the payer report
Complete PDSA cycles on measures to improve
Practice has made improvement to at least one measure.
In leu of cost utilization data practices can use “Choosing Wisely” as a tool to Decrease cost and utilization

Practice Facilitator Methodology:

Confirm practice has improved one metric.

BB10.3.3. Practice shares financial data transparently with staff and providers and develops their capabilities in understanding the organization’s finances and in using business practices and tools.

Action Items:

Practice has identified resources for educating staff at all levels in principles of business management, commensurate with their roles.
Practice is providing education and practice education and practice data on business metrics to staff at all levels across the organization.
Specialized training is being provided to those at the practice level that may be involved in analysis of alternative payment arrangements and in contracting for services.
Practice shares financial data in a transparent manner within the practice and has developed the business capabilities to use business practices and tools to analyze and document the value of the organization brings to various types of alternative payment models.

Practice Facilitator Methodology:

Confirm the practice has/does share financial data transparently and uses tools to make financial decisions.

SN.1.1. Practice performs an assessment of the social needs of their patient population and prioritize one or more condition for focused work.

Action Items:

Choose and implement a method for initial assessment of patient population's social needs:
- Patient surveys using existing social needs screening tools
- Speak with social workers, care managers, or other personnel at practice or in community who are currently assisting patients with social needs
- Examine population level data relevant to your local community
Have conversations with local community or governmental organizations to understand their perspective on the greatest social needs faced by your community. RHCs can facilitate these connections and offer their own insights into what the most common social needs are.
Share results with practice
Prioritize one or more social need for focused work. This decision is often made on the basis of (1) how common the need is, (2) ability to provide resources, and (3) implications for medical care.

Practice Facilitator Attestation Methodology:

Confirm practice has selected a method and created an action plan for assessing needs and identifying priority social need(s).

SN.1.2. Practice performs an assessment of community resources, with Regional Health Connector support, to assist patients/families with social needs (such as food, housing, transportation).

Action Items:

Work with your Regional Health Connector (RHC) to develop relationships with community and government organizations serving your patient population. Learn which social needs have available community resources, and which are more challenging to address.
Share results with practice.

Practice Facilitator Methodology:

Confirm practice assessment of social care resources. This can include the use of formal external assessments of such resources.

SN.2.1. Practice develops and implements a process to screen for the prioritized social need and to connect those who screen positive and desire assistance to appropriate resources.

Action Items:

Practice has engaged all levels of the practice to identify champions and establish a social needs workgroup.
Consider how the workgroup can obtain and incorporate patient input while developing screening processes.
Select screening tool to use and adapt as needed to fit the practice and patient population. Ensure that the tool asks patients if they would like to be referred for resources.
Develop workflow for social needs screening. Key decisions for workflow development:
- Which patients will be screened?
- How often will patients be screened?
- When does screening occur? (Before, during, or after the appointment?)
- How will the screener be administered? (Paper, electronic, or verbally?)
- Who will administer the screener?
- How will results be communicated to the provider (if the provider is not administering screening)?
- Where will screening data be stored? Contact EMR vendor, if applicable, to explore whether social needs screening tool can be added to the EMR.
- What scripting can staff use with patients to explain the social needs screening and why these questions are being asked?
- How will patients be referred for community resources? Ensure that referral processes comply with HIPAA information sharing standards.
Select resource directory or develop one for clinic use. Engage with RHCs regularly to ensure practice has access to most up to date resources.
Determine how practice will measure success of screening and referral program. Decide how this data will be shared with the practice to adapt processes that incorporate lessons learned.
- Patient, staff, provider satisfaction
- Numbers/rates of screening
- Numbers/rates of needs addressed
- Consider comparing data for different demographics to see if certain groups are being excluded, e.g. compare screening rates based on race, ethnicity, payer source, etc.

Practice Facilitator Methodology:

Practice has identified social needs champions and a workgroup. Practice has a documented screening workflow and plans for staff training. Practice has plan for collecting and reviewing screening data and improving screening practices.

SN.2.2. Practice develops community partnerships to support patients who have the prioritized social needs.

Action Items:

Practice has completed SN.1.2
With assistance from RHCs, identify one or more community organizations that address the selected social need(s) and has interest in/capacity for partnership.
Establish goals of partnership (Improved awareness of services, enhanced referral system, provision of services onsite at clinic, etc)
Establish mutually agreed on expectations for communication and general functions of the partnership.
Develop agreements on data use and data sharing.
Consider how the success of the partnership might be measured.
Practice continues to foster relationships and establish new relationships.

Practice Facilitator Methodology:

Confirm practice has developed community partnerships.

SN.2.3. Work with community partners and regional health connecters to identify at least one social need in your clinical population that is difficult to address through currently available community resources.

Action Items:

Practice has completed SN.2.1 and SN.2.2.
Practice convenes meetings with community partners and RHCs to discuss which social needs are particularly difficult to address with available community resources.

Practice Facilitator Methodology:

Confirm the practice is working with the community and regional health connectors.

SN.3.1. Practice develops and implements a process to screen for at least one additional social need and to connect those who screen positive and desire assistance to appropriate resource.

Action Items:

After completing SN.1.1, modify or change workflow to screen and refer for one additional social need.
Ensure that the resource directory used for SN 2.1 includes the new social need.

Practice Facilitator Methodology:

Confirm practice is screening for additional social need.

SN.3.2. Practice and community partners streamline information sharing to ensure patients’ social needs are being addressed.

Action Items:

Establish check in meeting with community partners to evaluate and update workflow.
If screening and referral workflow does not include collecting data on how often patients access the resource they have been referred to, consider conducting limited follow up with screened patients to learn more about the outcomes of community referrals given by clinic personnel.
Consider completing some or all of the Partnership Assessment Tool for Health (see below)

Practice Facilitator Methodology:

Confirm practice is working with partners and using bi-directional data sharing.

SN.3.3. Work with community partners and regional health connectors to advocate for expanded resources for previously identified under resourced social needs.

Action Items:

After completing SN.2.3, practice works closely with RHC to identify opportunities to advocate for policies that promote increased availability of the identified challenging resource.
Select advocacy strategy (meet with policymakers, write an op-ed or letter to the editor, participate in advocacy campaign led by advocacy organization, etc)
Follow up on chosen advocacy methods and continue communication with community partners and RHCs.

Practice Facilitator Methodology:

Confirm practice is advocating for resources.

Accountable Health Communities Health Related Social Needs Screening Tool (AHC HRSN)

Partnership Assessment Tool for Health

Partnership Models Between Community-Based and Health Care Organizations

PRAPARE Workflow Implementation Guide

PRAPARE;Assessing Pt Assets, Risks Experience

Principles for patient-centered approaches to social needs screening

Sample memorandum of understanding between a medical clinic and a food bank

WellRx Tool

SUD.1.1. Practice chooses a substance use screening tool (unhealthy alcohol use, opioid misuse, other drug dependence) and workflow for screening appropriate patients.

Action Items:

Practice has buy-in and resources available from leadership to screen and treat for substance use disorders.
Practice chooses a substance use screening tool appropriate for the substance use disorder they are tracking.
Practice convenes QI team or workgroup to establish clinical workflows.
Practice consults with EHR to check for integration and appropriate reporting.

Practice Facilitator Methodology:

Practice has screening tool selected and workflow planned.

SUD.2.1. Practice screens patients for risky substance use and provides interventions for patients and positive screens.

Action Items:

From SUD.1.1, practice uses screening tool and workflow to screen patients for substance use.
Practice provides interventions and/or referrals for those patients who screen positive.
Practice is able to follow up on positive screenings and referrals.

Practice Facilitator Methodology:

Confirms practice is screening patients.

SUD.2.2. Practice trains teams and prescribers on evidence-based treatments for alcohol use disorder or opioid use disorder.

Action Items:

Practice engages entire team to plan and institute training.
Practice establishes a training protocol for entire team.
Practice has a way to update and refresh training as needed.

Practice Facilitator Methodology:

Confirm practice has trained the team to provide treatment for AUD and OUD.

SUD.3.1. Practice implements documented process (including standing orders and follow up) for connecting patients/families with substance use issues to community resources.

Action Items:

Practice connects with Regional Health Connector for help in developing sources of community resources available to patients with substance use disorder.
Practice engages practice team to develop protocols and standing orders.
Practice is able to follows up with referrals and patients.
Practice confers with EHR to establish communication and referrals among team and community.

Practice Facilitator Methodology:

Confirm practice has a documented process for connecting patients to resources.

SUD.3.2. Practice provides outpatient medication assisted treatment for alcohol use disorder or opioid use disorder.

Action Items:

Practice trains at least one provider in practice for MAT for AUD or OUD. Please see free resources below for training.
Practice trains team in assisting with MAT.

Practice Facilitator Methodology:

Confirms practice has at least one provider who can provide MAT.

TH.1.1. Practice has determined services appropriate to provide through telehealth, including during emergencies such as the COVID-19 outbreak.

Action Items:

Practice has reviewed capacity and ability to provide telehealth services.
All members know their role in providing telehealth services to patients.
Triage is available to assist patients.
Practice has software in place to assist with telehealth.

Practice Facilitator Methodology:

Practice Facilitator verifies that practice has telehealth available to patients.

TH.1.2. Practice assesses their capacity to provide telehealth services and prioritizes one or more conditions.

Action Items:

Practice evaluates ability to provide telehealth visits to patients.
Practice evaluates what condition or conditions they will provide telehealth for.
Practice ensures adequate resources are available to provide telehealth services.

Practice Facilitator Methodology:

Confirms practice has completed assessment and has adequate resources.

TH.1.3. Practice can provide telehealth services to meet acute needs of patients in prioritized focus areas.

Action Items:

Practice has workflows in place for staff to provide acute patient visits.
Patients are informed about how they can make acute telehealth appointments.
Practice has communication with patient and verifies patient has technology to complete visit.

Practice Facilitator Methodology:

Confirms practice can provide acute telehealth visits.

TH.1.4. Practice utilizes telehealth services for outreach to patients overdue for primary care services.

Action Items:

Practice has workflow in place to identify patients who are overdue for a visit.
Practice has communication with patient and verifies patient has technology to complete visit.

Practice Facilitator Methodology:

Confirms practice is able to complete primary care visits using telehealth.

TH.1.5. Practice identifies their current payers reimbursing for telehealth services.

Action Items:

Practice reviews ability to receive reimbursement from Medicare, Medicaid, commercial payers and any others.
Practice is able to bill and document accordingly to payers and is receiving reimbursement for telehealth services.

Practice Facilitator Methodology:

Confirms practice is receiving payment for telehealth services from payers.

TH.2.1. The practice has mapped the workflow for providing, supporting and documenting telehealth services.

Action Items:

Practice has worked with entire team to develop and test a workflow/process for telehealth.
Workflow includes documenting appropriately for reimbursement in telehealth.

Practice Facilitator Methodology:

Confirms practice has a workflow for telehealth services.

TH.2.2. Practice identifies a platform to provide telehealth services to patients in prioritized focus areas.

Action Items:

Practice has identified software that is able to assist practice in providing telehealth services.
Practice will be able to bill and document in EHR for the telehealth visit.

Practice Facilitator Methodology:

Confirms practice has software available.

TH.2.3. Practice can provide telehealth services to meet prevention need of patients in prioritized focus areas.

Action Items:

Practice has workflows in place for staff to provide patient prevention visits.
Patients are informed about how they can make telehealth appointments.
Practice has communication with patient and verifies patient has technology to complete visit.

Practice Facilitator Methodology:

Confirms practice can provide prevention telehealth visits.

TH.2.4. The practice utilizes telehealth services for outreach to patients overdue for chronic care services.

Action Items:

Practice has workflows in place for staff to identify and provide overdue patient visits.
Patients are informed about how they can make telehealth appointments.
Practice has communication with patient and verifies patient has technology to complete visit.

Practice Facilitator Methodology:

Confirms practice can provide overdue chronic are services.

TH.2.5. Practice can bill and is getting reimbursed by Medicaid and Medicare for current telehealth visits with patients in prioritized focus areas.

Action Items:

Practice reviews ability to receive reimbursement from Medicare and Medicaid.
Practice is able to bill and document accordingly to payers and is receiving reimbursement for telehealth services.

Practice Facilitator Methodology:

Confirms practice is receiving payment from Medicare and Medicaid.

TH.3.2. Practice has a live platform and is providing telehealth visits to patients in prioritized focus areas.

Action Items:

Practice has identified software that is able to assist practice in providing telehealth services.
Practice has a workflow or procedure in place to assist staff with scheduling and providing services.
Practice will be able to bill and document in EHR for the telehealth visit.

Practice Facilitator Methodology:

Confirms practice has software available and in use.

TH.3.3. Practice can provide telehealth services to meet chronic needs of patients in prioritized focus areas.

Action Items:

Practice has workflows in place for staff to provide patient chronic visits.
Patients are informed about how they can make telehealth appointments.
Practice has communication with patient and verifies patient has technology to complete visit.

Practice Facilitator Methodology:

Confirms practice can provider chronic care visits to patients.

TH.3.4. The practice utilizes telehealth services for outreach to patients recently seen in the Emergency Department or recently discharged from the hospital.

Action Items:

Practice has workflows in place for staff to receive information around ED and/or discharged patients.
Clinical staff are able to contact patients and schedule telehealth appointments.
Practice has communication with patient and verifies patient has technology to complete visit.

Practice Facilitator Methodology:

Confirms practice has completed telehealth visits for recently discharged patients.

TH.3.5. Practice can bill and is getting reimbursed by commercial insurance for current telehealth visits with patients in prioritized focus areas.

Action Items:

Practice reviews ability to receive reimbursement from commercial payers.
Practice is able to bill and document accordingly to payers and is receiving reimbursement for telehealth services.
Practice Facilitator Methodology:

Confirms practice is receiving payment from commercial payers.

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Tools & Resources

CU Campuses

CU Anschutz Medical Campus

Practice Innovation Program

School of Medicine

Innovation Support Project (ISP)

ISP Implementation Guide (Interactive)

Building Blocks

Building Block: Inclusivity and Equity

Building Block 1: Engaged Leadership

Building Block 2: Data Driven Quality Improvement (QI)

Building Block 3: Empanelment

Building Block 4: Team-Based Care

Building Block 5: Patient and Family Engagement

Building Block 6: Population Management

Building Block 7: Continuity of Care

Building Block 8: Access

Building Block 9: Comprehensiveness and Care Coordination

Building Block 10: Value-based Contracting

Optional Focus: Addressing Social Needs of Patients

Optional Focus: Substance Use Disorder

Optional Focus: Telehealth

Practice Innovation Program

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Innovation Support Project (ISP)

ISP Implementation Guide (Interactive)

Building Blocks

Building Block: Inclusivity and Equity

Milestone 1- Practice leadership incorporates health equity into quality improvement initiatives

Milestone 2 - Practice develops and implements a process to routinely gather and update patient demographic information, including race, ethnicity, language, sexual orientation, gender identity, and disability status.

Milestone 3 - Practice includes consideration of patient demographics and health equity in quality improvement efforts.

Milestone 4 - Practice develops clear, holistic hiring processes that increase the diversity of team members

Milestone 5 - Practice implements a team-based communication strategy to improve engagement of all team members

Milestone 6 - Practice develops and provides individualized professional development for all staff

Milestone 7 - Practice recruits and retains members of the Patient Family Advisory Council (PFAC) that represent the diversity of the population served

Milestone 8 - Practice assesses the inclusivity of the practice through items on their patient experience survey

Milestone 9 - The practice identifies and addresses equity issues impacting patient access to care, including telehealth services

Building Block 1: Engaged Leadership

Milestone 1

Milestone 2

Milestone 3

Resources

Building Block 2: Data Driven Quality Improvement (QI)

Milestone 1

Milestone 2

Milestone 3

Resources

Building Block 3: Empanelment

Milestone 1

Milestone 2

Milestone 3

Resources

Building Block 4: Team-Based Care

Milestone 1

Milestone 2

Milestone 3

Resources

Building Block 5: Patient and Family Engagement

Milestone 1

Milestone 2

Milestone 3

Resources

Building Block 6: Population Management

Milestone 1

Milestone 2

Milestone 3

Resources

Building Block 7: Continuity of Care

Milestone 1

Milestone 2

Milestone 3

Resources

Building Block 8: Access

Milestone 1

Milestone 2

Milestone 3

Resources

Building Block 9: Comprehensiveness and Care Coordination

Milestone 1

Milestone 2

Milestone 3

Resources

Building Block 10: Value-based Contracting

Milestone 1

Milestone 2

Milestone 3

Resources

Optional Focus: Addressing Social Needs of Patients

Milestone 1

Milestone 2

Milestone 3

Resources

Optional Focus: Substance Use Disorder

Milestone 1

Milestone 2

Milestone 3

Resources

Optional Focus: Telehealth

Milestone 1

Milestone 2

Milestone 3

Resources

Practice Innovation Program

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