CHES QUARTERLY PTO MEETING. March 16, 11:00 AM 3:30 PM

CHES QUARTERLY PTO MEETING March 16, 11:00 AM 3:30 PM

INTRODUCTIONS Perry Dickinson

PROGRAM UPDATES Stacy Kramer, Heather Stocker, Allyson Gottsman

EVIDENCENOW SOUTHWEST UPDATES

ENSW Cohort 1 60 practices enrolled: 59/60 Practice Surveys and Practice Member Surveys sent Practice Surveys: 78% (n=47) complete Practice Member Surveys: 25 practices: >50% response rate 34 practices: <50% response rate 47/60 practices received PIP & DQIP 33 PIPs & 31 DQIPs returned 31 kickoff meetings start of 9 mo of PF/CHITA support Field notes / implementation tracking notes coming in Assessment / implementation stage: Enrollment Practice & Practice Member Surveys PIP & DQIP generated Kickoff Meeting 9 mo PF/CHITA support

Important Dates March: Recruitment for Cohort 2 April: Informational webinars for prospective practices May 6: Collaborative Learning Session #2 (Cohort 1) July: Cohort 2 practice facilitation begins Learning Community Dates: Monthly, 2nd Thursday : Office Hours / Q & A Monthly, 3rd Thursday : Topic-based / sharing best practices

Other ENSW Activities In-Depth Interviews / Practice Observation Understand contextual details affecting implementation and adoption of intervention Baseline, 9 mo, 15 mo, ~6 practices / cohort Half-day: 60 min interviews with clinicians, staff, administrators ENSW team seeking practice recommendations Willing to ask questions of interest to PTOs Send recommendations to Stacy.Kramer@ucdenver.edu Weekly PTO Newsletter ENSW updates Practice Status Reports Implementation Checklists

ENSW Cohorts 2 & 3 Cohort 2: Practice Facilitation starts July 2016 Cohort 3: Practice Facilitation starts October 2016 **All kickoff meetings (for all cohorts) occur by October 2016 ENSW Cohort 1 ENSW Cohort 2 ENSW Cohort 3 2016 2017 2018 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr Key: Cohort Recruitment Begins Practice Facilitation Begins/Kickoff Meeting Collaborative Learning Session Practice Facilitation Ends 15- month Practice Surveys & Practice Member Surveys

In Development. Final cohort timeline Timeline for practices what is due, when Updates to implementation checklists ENSW Resources on practiceinnovationco.org Streamlining communication across initiatives Contact lists Project team contact list (ENSW, SIM, TCPi)

QUESTIONS? FEEDBACK?

STATE INNOVATION MODEL (SIM) UPDATES

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Practice Types in SIM Cohort 1 Rural: 33 Pediatrics: 22 Mixed Pediatrics: 8 Hospital/System Owned: 26 FQHC: 18 Residency: 6 School-Based Clinics: 5 Underserved Population: 47 13

SIM RESOURCES http://www.practiceinnovationco.org/practices/resources/ 14

RESOURCES Getting Started with a Quality Improvement Teamin a SIM Practice Initiate formation of SIM Implementation/QI team with representatives from across the practice. Review the assessments with the practice. Milestone Inventory Medical Home Monitor IPAT Information gathered through these assessments will guide the practice in prioritizing and completing their Practice Improvement Plan. Complete Practice Improvement Plan with the practice. Identifies 3-6 practice goals to focus on over next six months. 1-2 Practice Transformation Goals 1-2 HIT Goals 1-2 Behavioral Health Related Goals Choose 1-2 high priority goals or 1-2 that the practice feels would be quick wins to work on first. Identify who will be accountable and by when and organize a PDSA test of change in the practice. Set twice monthly standing meetings with the QI Team.

RESOURCES e-learning: http://pto.pcmhelearning.com/#/login STREAMLINING & ALIGNMENT: As many PTOs are involved in ENSW and SIM the registration and username/password process has been streamlined to create an inclusive e-learning site for PTO training. The new site incorporates both the ENSW and SIM module sets as well as optional HIT modules. DUAL PURPOSE: 1. Provide overview of topics and helps ensure each PTO PF/CHITA is familiar with the key components for each project and for practice transformation. Additionally, information in the modules may prove useful when working in practices, specifically for: supporting practices time and energy for transformation efforts and practice activities can be used for newly formed or existing teams completed with PTO assistance. 2. Practices have access to the e-learning modules, your familiarity can further support their experience. Many practices have not had the opportunity to engage in e-learning for quality improvement. PTOs and practices are encouraged to visit and revisit the modules as often as you would like. 16

SIM Updates- Where are we in the process Kickoff and Initial Meetings Getting operational aspects in line: matching, SOW/POs, SPLIT access Learning Community Dates Monthly, 2nd Thursday : Office Hours / Q & A Monthly, 3rd Thursday : Topic-based / sharing best practices Completing Assessments Medical Home Practice Monitor, IPAT, Clinician and Staff Experience Survey 17

SIM Updates- SPLIT & Clinical Quality Measures (CQMs) SIM CQM Guidebook is in development and will be posted The FINAL CQM Document including numerators and denominators will be posted in the Resources Hub at the Practice Innovation Program CO website: http://www.practiceinnovationco.org/practices/resources/ 18

Who to Contact for What e-learning Technical Issues and Content Support - support@pcmhelearning.com Practice Facilitation- Including Collaborative Learning Sessions and Training Attestation Practice Transformation Program Manager - Stephanie Kirchner, Stephanie.Kirchner@ucdenver.edu SPLIT Technical Issues - support-split@practiceinnovationco.org Content Support SPLIT Project Research Assistant Lauren Shviraga Lauren.Shviraga@ucdenver.edu CHITA & Clinical Quality Measures (CQMs) HIT Program Manager - Maggie Dunham, maggie.dunham@ucdenver.edu 19

Contact Us SIM Practice Info Email: SIMPracticeInfo@ucdenver.edu Phone: 303.724.8968 Taryn Bogdewiecz, SIM Project Assistant Taryn.Bogdewiecz@ucdenver.edu Heather Stocker, SIM Project Manager heather.stocker@ucdenver.edu Practice Innovation Colorado Website: http://www.practiceinnovationco.org Colorado SIM Office: gov_simgrant@state.co.us 20

Collaborative Learning Sessions Registration For Both Opening This Week! Denver Metro Area May 6 th Western Slope- Grand Junction June 24 th In partnership with CO-Earth and Rocky Mountain Health Plans

THE TRANSFORMING CLINICAL PRACTICE INITIATIVE (TCPi) Colorado Practice Transformation Network: Lead the CHANGE

Transforming Clinical Practice Initiative (TCPi) Practice Transformation Network (PTN) Vision: Provide transformation support to 140,000 clinicians to achieve the quadruple aim and improve care for millions while reducing per capita costs through reduced hospitalizations and readmissions; avoidable ER visits, and unnecessary testing. Goal: Prepare the deliver system and providers for value-based compensation models. 23

TCPi Aims Support more than 140,000 clinicians Improve health outcomes for millions of patients Reduce unnecessary hospitalization for 5 million patients Generate $1 to $4 billion in savings Sustain efficient care by reducing unnecessary tests and procedures 24

Colorado Practice Transformation Network Measures of Success 1. Recruit 2000 clinicians by Sept 2016 Engage 2000 for up to 3.5 years through the 5 Phases of Transformation Eligible: Novice or advanced practices Primary care or specialists : medicine or procedural : in-patient or ambulatory An opportunity to think about supporting medical neighborhoods and communities 2. Improve on cost and quality measures Clinical quality measures (aligned with SIM quality measures) Cost/utilization measures total population Hospitalizations, Readmissions, ED Visits, Reduced low back imaging 3. Goal 75 % of enrolled clinicians participate in value based compensation programs by 2019 25

Eligible Clinicians PCPs and Specialists: MDs, DO s, PA s APN s (at the NPI level, not TIN level) Eligible: Evidence NOW SW; possibly SIM NOT ELIGIBLE: participating in CPCi, Medicare Shared Savings Payments (ACO) 26

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Colorado PTN Methodology: A Hybrid Similarities: Baseline Assessment Practice Improvement Plan Submit measures Collaborative Learning Sessions Change package similar to building blocks content Differences: Limited on-site coaching 6 visits Primary intervention: Virtual Learning Network 28

TCPi Methodology: Two Levels of Support At the Practice Level: Practice assessment using national practice assessment tool (PAT) Review current clinical, cost and utilization data; discuss learning network possibilities Connect with PTO Select a provider champion and a staff champion Champions training with other champions from their learning network Relationship building Leadership development Change management Basic QI How to be a learner and contributor in a virtual learning model Work with PF 6 visits over time build relationship, form a team, QI basics Monthly call (30 minutes) with provider and staff champion 29

TCPi Methodology: Two Levels of Support At the Learning Network Level: Virtual learning network of 10-12 practices facilitated by a PF; supported by expert faculty Practices are accountable to each other for agendas; rotate leading the meeting; PF is available as a resource Use the Project ECHO framework 10-15 minutes of content delivery by expert Practice shares their experience testing the content in a case study format Others offer suggestions or questions Practices share and learn from each other Utilize vetted tools from national organizations Content support material developed by faculty and DFM staff 30

Colorado Practice Support Methodology Learning Networks may be organized by: Specialty Geography Health Systems Referral Networks 31

How will TCPi content be organized? Patient and Family Centered Care Design Continuous, Data-Driven Quality Improvement Sustainable Business Operations

Patient and Family Centered Care Design Patient and family engagement Team-based relationships Data Driven QI Population management Practice as a community partner (medical neighborhood) Coordinated care delivery Organized, evidence based care Enhanced access Sustainable business operations

What is MACRA? The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is a bipartisan legislation signed into law on April 16, 2015. What does MACRA do? Repeals the Sustainable Growth Rate (SGR) Formula Changes the way that Medicare rewards clinicians for value over volume Streamlines multiple quality programs under the new Merit-Based Incentive Payments System (MIPS) Provides bonus payments for participation in eligible alternative payment models (APMs)

Questions?

LUNCH/BREAK

RECRUITING Allyson Gottsman

All Programs Preparation for future models of compensation SIM and TCPi dedicated content to help build the infrastructure for value based payment Practice support and learning network with peers Continuing Medical Education(CME) and Maintenance of Certification (MOC)

EvidenceNOW SW Benefits: Opportunity to begin transformation and build competency needed for new models of care and compensation (example PCMH) Shorter commitment: 9 months of coaching CHITA support to optimize EHR and data Building Blocks 1 6 Good preparation for SIM: requires basic infrastructure (team based care, population management) Opportunity to work on CVD May be randomized to engage patients and families in the QI process Only 4 measures

SIM Benefits: Financial: Payer support $5000 incentive payment Small grant fund: apply for funding to support BH integration Work on behavioral health in a learning environment Strengthen advanced primary care competencies Work on cost reduction Cost and data utilization data feedback

TCPi Benefits: Less intense, longer duration Virtual learning network with peers Opportunity to build cohesive medical neighborhood For specialists: high value referrals For PCPs: access to specialty care; good feedback loops, Professional development for champions in practice improvement Journal Club of the 21 st Century Support from national SANs AMA and ACP: great electronic modules Radiology clinical decision support Psychiatry training in Collaborative Care Model Work on cost reduction Cost and utilization data feedback

Questions?

REGIONAL HEALTH CONNECTOR UPDATE Ashlie Brown and Sarah Lampe

Regional Health Connectors Strengthening Community Partnerships Colorado Health Extension System Quarterly PTO Meeting March 16, 2016 Sarah Lampe, MPH Program Director Ashlie Brown Director of the SIM Extension Service The Project described was supported by Funding Opportunity Number CMS -1G1-14-001 from the US Department of Health and Human Services, Centers for Medicare and Medicaid Services.

Regional Health Connectors (RHCs) are a new resource to help facilitate clinical-community linkages and to help communities improve coordination of local services for residents. Existing community organizations will host RHCs to strengthen partnerships between providers, public health, human services and communities RHCs will help local partnerships review existing initiatives and focus on one or two key interventions aligned with statewide goals.

Coordination with practice transformation Programs Workforce Practice Facilitators Clinical HIT Advisors Regional Health Connectors

from the community perspective

Connecting panel health to population health Julesburg Tim Valley Medical Clinic hypertension patient panel Residents of Sedgwick County

Colorado Health Statistics Regions (HSR) 49

Activities of the Regional Health Connectors Work with local partnerships of providers, public health, human services, and local organizations to: 1.Review existing initiatives and data. 2.Align on local priorities. 3.Identify opportunities for coordination. 4.Develop an implementation plan for coordination. 5.Find additional resources.

Deep Dive: Goals and program-specific responsibilities 51

Program: EvidenceNOW Southwest (ENSW) EvidenceNOW Southwest will serve up to 260 primary care practices across Colorado and New Mexico with practice transformation and quality improvement support, including on-site practice facilitation and coaching, expert consultation, shared learning collaboratives, and electronic health record support. http://www.evidencenowsw.org/ 52

Program: State Innovation Model (SIM) Improve the health of Coloradans by: providing access to integrated primary care and behavioral health services in coordinated community systems; applying value-based payment structures; expanding information technology efforts, including telehealth; and finalizing a statewide plan to improve population health. https://www.colorado.gov/healthinnovation 53

Regional Health Connector Goals Local relationships and priorities in each region will drive the work of each RHC, guided by the framework of four common goals: 1. Address local priorities within program target areas 2. Support practice transformation efforts 3. Support population health strategies 4. Address Social Determinants of Health 5. Build/strengthen regional partnerships 54

Goal 1. Address local priorities in target areas Target Area ENSW Alignment between Statewide Initiatives SIM CO Winnable Battles CO Opportunity Project CPCI Hypertension Obesity Prevention Asthma Diabetes Safety Depression Anxiety Substance Use Child Development Cardiovascular Disease ACC 55

Goal 2. Support practice transformation efforts Bodenheimer T, Ghorob A, Willard-Grace R, Grumbach K. The 10 building blocks of high-performing primary care. Ann Fam Med. 2014;12(2):166 171. 56

Goal 3. Support population health strategies 57

Goal 4. Address Social Determinants of Health 58

Goal 5. Build/strengthen regional partnerships 59

Next Steps: Building the RHC workforce 60

Coordination Between Programs Each region will have one Regional Health Connector EvidenceNOW Southwest will fund 6.0 FTE at five RHC host organizations: Colorado Foundation for Public Health and Environment Rocky Mountain Health Plans Centennial Area Health Education Center Community Health Partnership Otero County Health Department The SIM Extension Service will fund 15.0 FTE 61

SIM RHC Host Organization Selection Process Competitive process to select additional RHC hosts Hosts will be existing entities within the community. Hosts may reassign existing staff or hire new staff. The SIM Extension Service is coordinating closely with ENSW and other CHES partners to minimize duplication More details by the end of March. 62

Regional Health Connectors (RHCs) are a new resource to help facilitate clinical-community linkages and to help communities improve coordination of local services for residents. Existing community organizations will host RHCs to strengthen partnerships between providers, public health, human services and communities RHCs will help local partnerships review existing initiatives and focus on one or two key interventions aligned with statewide goals. 63

Questions? Sarah Lampe, MPH Program Director slampe@cfphe.org Ashlie Brown Director of the SIM Extension Service browna@coloradohealthinstitute.org www.cfphe.org www.coloradohealthinstitute.org

INVOICING PROCESSES Rebecca Rapport and Natalie Buys

ENSW Contracts Managed by CFPHE Fixed-Price Award Example: PTOs in ENSW Set value is given to deliverables Payments are associated with individual SOWs for individual practices Meet deliverables, get paid Contracts maintain flexibility CFPHE takes on administrative burden Cost-Reimbursable Funding Example: RHC contracts at local agencies Based on actual expenditures Payments are associated with the spending of allowable costs from an overall budget Receipts and other proof of payment must be submitted with invoices

ENSW Payment Process: One Month Timeline Ongoing PTO submits deliverables to UCD as they are finished Ongoing CFPHE emails the PTO a report of the month showing: Deliverables that are complete for each practice Amount PTO can expect to be paid that month, based on SOW phases First week of month By mid-month PTO receives payment directly from CFPHE PTOs are not invoicing CFPHE, and do not need to track deliverables outside of submitting them End of month UCD reviews deliverables, then sends completion reports to CFPHE If needed, PTO revises existing or submits additional deliverables UCD updates CFPHE of any changes

Who to Contact about ENSW Payments Invoices, payment amounts, reporting, feedback on SOWs: tspector@cfphe.org Questions about deliverable content and submission process: Stacy.Kramer@ucdenver.edu Practice cohort changes or dropouts (new SOWs): ikane@cfphe.org

SIM PTO Invoicing All SIM Invoicing will be completed through the University of Colorado Match between PTO and Practice Standing Purchase Order (SPO) issued by UCD s Procurement System MarketPlace Separate SPO for Practice Facilitation and CHITA services Scope of Work for each service attached Contact person identified to receive purchase orders on behalf of the PTO will receive email

Invoicing Once a set of deliverables is complete per the Scope of Work attached to the SPO, PTO s can invoice Invoices should include: SPO Number Bill To Bill From Date Deliverables Completed Amount being Invoiced Cumulative Amount Invoiced to Date

Who to Contact about SIM Payments Invoices, payment amounts, SPOs and submission process: Natalie.Buys@ucdenver.edu Questions about deliverable content and practice cohort changes or dropouts: SIMPracticeInfo@ucdenver.edu

QUALITY ASSURANCE PROCESS Perry Dickinson and Allyson Gottsman

LEARNING COMMUNITY Stephanie Kirchner

Learning Community Office Hours is an open forum to address questions, concerns, and problem solving related to practice facilitation (PF) and clinical health information technology advisor (CHITA) work in the field. Stephanie Kirchner, Practice Transformation Manager, and Maggie Dunham, HIT Program Manager, will host these sessions. Office Hours begin March 10 and will continue the second Thursday of every month, 10:00 AM - 11:00 AM. Learning Community Features provide an open forum for sharing best practices, learning from one another, and networking. Topics will be presented each month to frame these discussions. We look forward to PTO s suggesting topics and content. Sessions begin April 21 and will continue the third Thursday of the month, 10:00 AM - 11:00 AM.

Questions and Answers

WRAP UP

AGENDA CHES QUARTERLY PTO MEETING March 16, 2016 Founders Boardroom, COPIC Office, 7351 E. Lowry Blvd., Denver 11:00 AM 3:30 PM 11:00 11:10 Introductions Perry Dickinson 11:10 12:10 Program Updates and Questions EvidenceNOW SW Stacy Kramer 15 minutes SIM Heather Stocker 15 minutes TPCi Allyson Gottsman 30 minutes 12:10 12:30 Lunch/Break 12:30 1:00 Features of Initiatives for Recruitment EvidenceNOW SW SIM TCPi Allyson Gottsman 1:00 1:30 Regional Health Connector Update Ashlie Brown and Sarah Lampe 1:30 2:00 Invoicing Processes Natalie Buys and Rebecca Rapport 2:00 2:30 Quality Assurance Process Review QA Process Review Selection Process for PTOs on QA Committee Characteristics of Quality Assurance Committee Member Perry Dickinson and Allyson Gottsman 2:30 3:15 Learning Community and Q&A Stephanie Kirchner 3:15 3:30 Wrap Up Summarize Action Items

CHES PROGRAMS OVERVIEW- For Recruitment EvidenceNOW Southwest (ENSW) Program Description Eligibility Focus Measures Target Practices / Benefits Timing: Wave 2: July 2016 April 2017 Wave 3: Oct 2016 July 2017 Practice assessment with individualized practice plan for practice transformation, data quality improvement, and improving cardiovascular risk 9 months on-site practice support: Practice Facilitation (PF) Clinical Health Information Technology Advisor (CHITA) Regional Health Connector (RHC) 2 Collaborative Learning Sessions Enhanced intervention for some practices ( approximately 50%) to address patient engagement in practice transformation activities Primary care serving adult patients Fewer than 10 providers (not FTEs) Practice has ability to make its own decisions regarding transformation changes EHR not required Build infrastructure to develop and implement processes and systems to reliably deliver and measure evidence based care Content: Cardiovascular Risk Mitigation Practice and Practice Member Survey s Aspirin Blood Pressure Control Cholesterol Management Smoking Cessation Submitted quarterly for 15 months Support in developing competencies needed for PCMH, ACOs, SIM, and other advanced models of care Limited engagement 9 months, try the coaching model to see if it works for the practice $500 stipend Target: For practices newer to transformation - good introduction to transformation support and preparation for SIM or other programs Opportunity for advanced practices to embed new CVD guidelines to improve care for patients with CVD Half of practices will receive enhanced support for patient and family engagement and addressing social determinants of health

State Innovation Model (SIM) Program Description Eligibility Focus Measures Target Practices / Benefits Timing: Cohort 2: Feb 2017 Jan 2018 Apply Summer 2016 Cohort 3: Feb 2018 Jan 2018 Apply Summer 2017 Methodology: Practice assessment with feedback, development of individualized Practice and Data Improvement Plan 2 years of practice support: Practice Facilitation (PF) Clinical Health Information Technology Advisor (CHITA) Regional Health Connector (RHC) 2 Collaborative Learning Sessions per year regional Primary Care Practices EHR required Some experience with practice transformation preferred Advanced model of primary care to include behavioral health integration, alternative payment models, and community engagement Behavioral Health defined to include: mental health, health behavior changes, and substance use disorders SIM supports flexible approach to how a practice integrates behavioral health; many approaches can work including: wellcoordinated care, colocated behavioral health professionals and integrated models of care Practice and Practice Member Surveys Link to SIM measures and description of requirements Submitted quarterly On-site practice support Availability of tools and support for both practice transformation and behavioral health integration Advanced payments from payers for SIM and increased engagement with payers as they move into advanced payment models Good introduction to value-based contracting as payers will be supporting practices using alternative payment methods to conduct SIM activities. Additionally behavioral health integration has been shown to reduce cost of care, a bonus for future valuebased contracts.

Transforming Clinical Practice Initiative (TCPi) Program Description Eligibility Focus Measures Target Practices / Benefits Timing: Recruiting through July 2016 Support up to 3.5 years (Sept 2019) Methodology: A. Baseline assessment B. Develop Practice and Data Improvement Plan C. Initial on-site coaching to develop: o QI basics o Team based care o Work flow process improvement tools o Measures and data D. Two practice champions from each practice selected, trained in QI basics and leadership in one-day session E. Champions join a virtual learning network - 10-12 practices working on common issues, monthly calls led by practice facilitator to discuss key topics, progress, lessons learned F. 2 Collaborative Learning Sessions per year one with learning network, one with larger regional group ALL Providers: MD s, DO s, NP s, PA s Primary Care and Specialists Not eligible: CPCi practices Medicare Shared Savings Plan Providers Delivery system redesign to succeed in value-based payment models, including MACRA Change Package: includes building block competencies, plus business training around value based models Practice Surveys Link to TCPi Measures Quality measures aligned with SIM, plus cost measures Total cost of care Hospitalization ED visits Reduce unnecessary low back imaging Unique measures for specialists Support for improvement within the practice as well as across a network of practices Less time commitment per month, longer duration (up to 3.5 years) Excellent for Health Systems, IPAs, regional communities of care - all who will work together to contract for value based care and need a cohesive network of providers Support to build the business tools and infrastructure for value-based models Good for practices needing foundational practice redesign, preparation for value based payment, and/or working within a medical neighborhood

TCPI Change Package: Transforming Clinical Practice Primary Drivers Organize clinical practice around three management functions that will drive performance, quality, and business success. 1. Person and Family-Centered Care Design PERFORMANCE 2. Continuous, Data-Driven Quality Improvement QUALITY 3. Sustainable Business Operations SUCCESS Person and family centered care design allows the practice to combine the evidence base with the voice of patient and family. It allows the practice to tailor care delivery to meet the needs of individual patients and the entire population served. Through the coordinated efforts of an expanded care team, in partnership with patients, families, and community, the practice can promise results. Continuous, data driven quality improvement reflects the practice s commitment to quality. It s about understanding performance at all levels and bringing systems, technology, and people together to make the practice better in many ways. It means empowering every person in the practice to innovate and improve. Sustainable business operations provide the Infrastructure and capabilities to support the right workforce, efficient workflows, and a high value product. Success is seen in positive patient experiences, staff that experience joy in work, and resources for investing in the practice s future. v2.0 Last updated March 7, 2016

Secondary Drivers 1. Person and Family-Centered Care Design To achieve a person and family-centered care delivery system, seven key drivers should be considered: 1.1 Patient and family engagement 1.2 Team-based relationships 1.3 Population management 1.4 Practice as a community partner 1.5 Coordinated care delivery 1.6 Organized, evidence-based care 1.7 Enhanced access 2. Continuous, Data-Driven Quality Improvement To achieve a practice culture of continuous quality improvement, three key drivers should be considered: 2.1 Engaged and committed leadership 2.2 Quality improvement strategy supporting a culture of quality & safety 2.3 Transparent measurement and monitoring 2.4 Optimal use of HIT 3. Sustainable Business Operations To achieve a practice with long-term sustainable business operations, four key drivers should be considered: 3.1 Strategic use of practice revenue 3.2 Workforce vitality and joy in work 3.3 Capability to analyze and document value 3.4 Efficiency of operation

Change Concepts 1. Person and Family-Centered Care Design 1.1 Patient and family engagement 1.1.1 Respect values and preferences 1.1.2 Listen to patient and family voice 1.1.3 Collaborate with patients and families 1.1.4 Be aware of language and culture 1.2 Team-based relationships 1.2.1 Enhance teams 1.2.2 Clarify team roles 1.2.3 Optimize continuity 1.2.4 Define specialty-primary care roles 1.3 Population management 1.3.1 Assign to panels 1.3.2 Assign accountability 1.3.3 Stratify risk 1.3.4 Develop registries 1.3.5 Identify care gaps 1.4 Practice as a community partner 1.4.1 Community health needs 1.4.2 Community collaboration 1.4.3 Identify social determinants 1.4.4 Use community resources 1.4.5 Be transparent 1.5 Coordinated care delivery 1.5.1 Manage care transitions 1.5.2 Establish medical neighborhood roles 1.5.3 Coordinate care 1.5.4 Ensure quality referrals 1.5.5 Manage medication reconciliation 1.6 Organized, evidence-based care 1.6.1 Consider the whole person 1.6.2 Plan care 1.6.3 Implement evidence-based protocols 1.6.4 Decrease care gaps 1.6.5 Reduce unnecessary tests 1.7 Enhanced access 1.7.1 Provide 24/7 access 1.7.2 Meet patient scheduling needs 1.7.3 Create patient-centered spaces 1.7.4 Mitigate access barriers

2. Continuous, Data-Driven Quality Improvement 2.1 Engaged and committed leadership 2.1.1 Commit leadership 2.1.2 Develop a roadmap 2.1.3 Create a shared vision 2.2 Quality improvement strategy supporting a culture of quality and safety 2.2.1 Use an organized QI approach 2.2.2 Build QI capability 2.2.3 Empower staff 2.2.4 Share learning 2.3 Transparent measurement and monitoring 2.3.1 Use data transparently 2.3.2 Set goals and benchmarks 2.4 Optimal use of HIT 2.4.1 Innovate for access 2.4.2 Share information through technology 2.4.3 Use technology supporting evidence 2.4.4 Use technology for partnerships 2.4.5 Drive efficiency through technology 3. Sustainable Business Operations 3.1 Strategic use of practice revenue 3.2 Workforce vitality and joy in work 3.3 Capability to analyze and document value 3.4 Efficiency of operation 3.1.1 Use sound business practices 3.1.2 Use patient as customer feedback 3.1.3 Consider non-traditional revenue 3.1.4 Benefit from performance payments 3.1.5 Drive performance excellence 3.1.6 Ensure business accuracy 3.2.1 Encourage professional development 3.2.2 Hire for fit 3.2.3 Cultivate joy 3.2.4 Improve quality time 3.2.5 Reward and recognize 3.3.1 Manage total cost of care 3.3.2 Develop data skills 3.3.3 Develop financial acumen 3.3.4 Document value 3.4.1 Streamline work 3.4.2 Eliminate waste 3.4.3 Maximize provider value