1. Collaborative Care: Proactively engaging patients Innovate on the Provider Exam Locums Group Visit Group On-boarding Home Visit Virtual Visit Mobile Clinic Fast Track Urgent Care Urgent Care Extended Hours Provide Team Care Behaviorist Medical Assistants Nurse/ Complex Care Manager Pharmacy Visits LCSW Community Linkage On demand education programs Care (Health) Navigators Community-based delivery Health Fairs Follow Up Health (Patient) Portal Email/Secure Message Nurse Advice Call Lines Call Center Connect to Peer Support Lay-led groups Web-based support Promotoras Gather Clinical Data Proactive outreach phone/mail/ text IVR Calls Remote monitoring Gather Patient Experience Health Risk Assessment PAM/ HARMS-8 PREPARE CONNECT ENGAGE Triple Aim Improved Population Health and Well Being Excellent Patient Experience Team Engagement & Retention Reduced Cost MacColl Center for Health Care Innovation & Oregon Primary Care Association. 2014

2. Gather Patient Experience data ApproachDescriptionExamples Health Risk Assessment HARMS-8 (Hospitalization Admission Risk Monitoring System) Evaluation of health risks and quality of life, patients stratified New Mexico Medicaid Managed Care Organizations Patient Activation Measure (PAM) The PAM measures the extent to which 1) patients know how to manage their condition, 2) have the skills and behavioral repertoire to manage their condition, and 3) have the confidence that they can collaborate with their health providers, maintain functioning, and access appropriate and high quality care. Alan Glaseroff, Stanford Coordinated Care Clinic

3. Gather Clinical Data ApproachDescriptionExamples Telephone visits Telephonic visits in lieu of face to face or as a way to prepare for the visit. Currently, OHA won’t allow “new” patients to be established this way. Option for established patients. Consider looking at schedules, combing, and calling all patients for whom a call might work - would create new slots for those new to CHC. Lone Star, Texas First Health reimburse $25 Wright Center, Scranton PA Mail Letters + requests via postal address, proactive outreach for folks with chronic disease care, preventive care. Group Health Birthday Letters TextText messagingText-4-Baby Interactive Voice Recognition Technology (IVR) Campaigns of outbound robo calls using IVR for targeted messaging and reinforcement. Family Care, California Remote monitoringTechnology to remotely monitor patients using Bluetooth and digital connections. Common for diabetes, CHF and asthma. Health Buddy

4. Provide Team Care ApproachDescriptionExamples Behaviorist The BHC provides brief, targeted, real-time assessments/interventions to address the psychosocial aspects of primary care. Oregon Medical AssistantsConduct health coaching Scribing as a way to improve provider/patient relationship and flow Career ladder for developing Medical Assistant skills Prepares for, attends and participates in team meetings and huddle(s)  Responsible for patient flow on day of visit  Completes required pre-visit and visit preparation using the MA Standards of Care checklist  Reviews and completes any overdue health maintenance and open orders at every visit  Completes appropriate documentation of questionnaires  Completes follow up work after visit  Completes planned care team outreach assignments between visits  Maintains room stocking Patient Facilitator/Navigator/Health Coach Career Ladder. (3:1 ratio) Starts with immunization, minor procedures, then referral coordination, tracking progress, then motivational interviewing University of California, San Francisco Teamlet Miramont Family Medicine, CO Union Health Center, New York City Cambridge Health Alliance High Plains, Colorado

5. Provide Team Care ApproachDescriptionExamples Nurse/Complex Care Manager, Assess new patients, identify patient problems/needs, self-management support, follow up, navigate specialists/referrals, titrate medicine, target complex, high needs patients, proactive outreach and triage. Sebastopol, CA Patient Navigator Harvard Vanguard, MA Medication Mgmnt NeighborCare, WA Role Clarity Johns Hopkins, MA Guided Care Group Health, WA Wellness Visit Pharmacy Visits Pharmacists do medication management and reconciliation. Provide care for patients with acute exacerbation between visits on the phone (usual) or in person (language issues/disability). All new patients with RXs start with pharmacist. South Central FDN Ashville Model St. Peter Family Medicine, Olympia WA LCSWAugmenting the patient’s primary care encounter by address gaps in care, provide support to meet patients’ medical and psychosocial problems, assess patients’ psychosocial considerations and their impact on medical status and educate providers how to support patient self- management. 11 th Street Family Health Services of Drexel University, Philadelphia PA

6. Innovate on the Provider Exam ApproachDescriptionExamples Locums Physician who works in the place of the regular physician when that physician is absent, or when a practice. Group Health, WA Group Visits, Drop in Medical Appointments (DIGMA) Disease specific groups Disease Clinics Mini-group visits – MAs as specialists in Diabetes and Chronic Pain Clinica Campasena, Colorado St. Peter Family Medicine, Devin Sawyer Group On-boarding Cohorts on-boarded as a group Perinatal, Behavioral Health, Military, AA Home VisitsCare team goes into the home In Home Primary Care, Snohomish Co, WA Virtual visits Using iPads and Skype. Long haul trucker pulls over and Skypes in for virtual visit to monitor diabetes. North Carolina Mobile clinicsMobile vans go into the community for services. Tennessee Call Doc San Diego Fast track urgent care Dedicated provider providing fast track open access model. “Red Team” urgent care linked to primary care team. Patient can visit 4x then have to be seen in the clinic. Fills no-show spots ‘upstairs’ in primary care first. Harpers Ferry Family Care WV Unity Health Care, Washington DC Urgent Care CentersFQHC owned urgent care model. Family Care Clay County WV Extended HoursMorning (8-9) and evening (5-8) and Saturday hours shared by rotating existing care teams. High Plains, Colorado

7. Connect to Peer Support ApproachDescriptionExamples Lay-led Groups Living Well With Chronic Conditions Humboldt Del Norte IPA Web- based peer support Communities of peer based groups providing self- management support. Social networking Big White Wall focused on behavioral health anonymous peer support augmented by health professionals Facebook, Twitter, Instagram PromatorasLay workers coordinate peer support on disease states (e.g. diabetes). Access Community Health Network, Chicago IL

8. Community Linkage ApproachDescriptionExamples On demand education programs Care (Health) Navigators Health coach assigned to high risk patients to help navigate their illness and care system. Eric Coleman model out of Colorado Community-based delivery Care team uses community based facilities to create access and meet patients where they live and work. Aaron E Henry Mississippi Church Gardens and visits after church Health FairsCommunity based periodic health fairs aimed at large scale outreach. Dental marathon in West Virginia

9. Follow-Up ApproachDescriptionExamples Health (Patient) portals,Web based access to information, scheduling, results reporting. Missouri Miramont Family Medicine,CO Email/Secure MessagingFor routine questions and answers. (24 7) Nurse Advice Call lines, Triage services with high diversion rates. Call centerClinic follows up from visit by phone to ensure care plan is understood and all questions addressed. Lone Star, Texas

10. Resources Compiled by Katie Coleman MSPH MacColl Center at Group Health Research Institute & Roger Chaufornier CSI Solutions LLC 7/17/2014 Hospitalization Risk Screening Tool for Primary Care Providers and Teams (HARMS-8). Used by a variety of practices and plans, including Stanford’s Coordinated Care Clinic and Dr. Alan Glaseroff. (Hard copy available) Patient Activation Measure. Created by Judith Hibbard PhD and now owned and managed by Insignia Health. A validated measure of patient activation, this tool comes in various lengths and languages. More information at http://www.insigniahealth.com/solutions/patient-activation- measure/what-a-pam-score-reveals. (Accessed 7/17/14)http://www.insigniahealth.com/solutions/patient-activation- measure/what-a-pam-score-reveals Cambridge Health Alliance Team-Based Care Leadership Team. “Cambridge Health Alliance Model of Team-Based Care and Implementation Guide and Toolkit.” Boston, MA. Cambridge Health Alliance is a forward-thinking safety-net health system in Massachusetts. (Hard copy available) Chan K “Improving New Patient Access: Orientation Clinic” Chinatown Public Health Center. SF Quality Culture Series. March 12, 2013. (Hard copy available) Screening, Brief Intervention, Referral to Treatment (SBIRT). See www.sbirtoregon.org for more from the Oregon Health and Science University.(Accessed 7/17/14) AND for more on integrating behavioral health broadly, Collins C, Hewson DL, Munger R and Wade T. “Evolving Models of Behavioral Health Integration in Primary Care.” Milbank Memorial Fund. 2010. (Hard copy available)www.sbirtoregon.org Union Health Center’s explanation of their MA career ladder. Union Health Center is an FQHC in New York City. Published May 9, 2014. http://www.youtube.com/watch?v=01MD4o5jGng&list=TLjmCRpZeQu-YYMjbOHYjp4DvfGip-SXkY (Accessed 7/17/14). http://www.youtube.com/watch?v=01MD4o5jGng&list=TLjmCRpZeQu-YYMjbOHYjp4DvfGip-SXkY Tantau C. “Optimizing your Care Team.” Tantau and Associates, LLC. Chicago Park CA. This PPT includes information about optimizing your care team and an excellent case study at the end about clearly defining the RN role by Katie Bell, COO of NeighborCare Health, a high performing FHQC in Seattle WA. (Hard copy available) Guided Care: Comprehensive Primary Care for Complex Patients. Based on research conducted by Chad Boult MD and team at Johns Hopkins university, this website offers specific job descriptions, and other resources for effective use of RNs as complex care managers in small office practices. More information at: www.guidedcare.org (accessed 7/17/14).www.guidedcare.org Decreasing Demand for Appointments. Institute for Healthcare Improvement. {Hard copy attached} Group Health Cooperative. “Group Visit Starter Kit” 2001. A classic on how to get started with group visits. Available at www.improvingchroniccare.org. (Hard copy available)www.improvingchroniccare.org Davis AM, Sawyer DR, Vinci LM “The Potential of Group Visits in Diabetes Care.” Clinical Diabetes Volume 26:2 11/2/2008. (Hard copy available) Emanuel EJ “Hi, It’s Your Doctor.” New York Times Opinionator. 9/5/2013. Available at http://opinionator.blogs.nytimes.com/2013/09/05/hi-its-your- doctor/ ( Accessed 7/1/7/14).http://opinionator.blogs.nytimes.com/2013/09/05/hi-its-your- doctor/ Living Well with Chronic Conditions is also known as Chronic Disease Self-Management (CDSMP). This program was developed by Kate Lorig and colleagues out of Stanford and is established in many communities including in Oregon and Washington. More information is available at Stanford’s School of Medicine/ Patient Education at http://patienteducation.stanford.edu/programs/cdsmp.html (accessed 7/17/14).http://patienteducation.stanford.edu/programs/cdsmp.html Bureau of Health Professions, HRSA, HHS “Community Health Worker National Workforce Study.” at http://bhpr.hrsa.gov/healthworkforce/reports/chwstudy2007.pdf (Accessed 7/17/14). http://bhpr.hrsa.gov/healthworkforce/reports/chwstudy2007.pdf National Learning Consortium. “Using Patient Portals in Ambulatory Care Settings” HealthIT.gov (Hard copy available) Emont S “Measuring the Impact of Patient Portals: What the Literature Tells Us.” California Health Care Foundation May 2011. (Hard copy available) Lattier V et al “Safety and effectiveness of nurse telephone consultation in out of hours primary care: randomized controlled trial”. BMJ Volume 317. 10/17/1998. (Hard copy available) Bunn F, Byrne G, Kendall S “Telephone consultation and triage: effects on health care use and patient satisfaction (review)”. Cochrane Collaboration. The Cochrane Library. 2009. Issue 1. (Hard copy available)