1. Knowledge for Improvement: Best Practices in Primary Care Transformation Rachel Wallis, MPH, and Emily Glynn

2. Session Objectives  List key concepts to consider when implementing the medical home model of care.  Identify patterns of success in both small/ independent practices and system-affiliated practices.  Analyze practice case studies and success stories to identify actionable processes for replication.  Discuss how different practice settings can achieve a similar goal with the right processes.

3. Who We Are and What We Do  Comprehensive Primary Care initiative (CPC)  TMF Health Quality Institute

4. 5 Functions of Comprehensive Primary Care (CPC)  Risk-stratified care management –In-between visits, care manager touches, empanelled patients, number risk-stratified  Access and continuity –Portals, e-visits, 24/7 access, portal acceptance, continuity, visit availability  Planned care for chronic conditions and preventive care –Age/sex health maintenance, example of care manager form, CQM  Patient and caregiver engagement –Shared decision-making, patient satisfaction, shared-decision aids  Coordination of care across the medical neighborhood –Hospital transitions, readmissions, admissions, care agreements

5. Key Components of Practice Transformation  Bi-directional communication  Teaming/Engagement/Leadership  Risk-stratified, protocol-driven, patient-focused care management  Using data to guide improvement

6. System Practice Transformation 6

7.  Communication –Leadership structure Dyad Rounding –Structured meetings Team approach –Clinic improvement hours

8. Autonomy vs. Standards  Standards –Risk stratification –SDM (EMR)  Autonomy –CQM –Improvement projects

9. Learning New Skills  Effective meetings  Process improvement knowledge  Data boards – understanding data

12. Small/Independent Practice Transformation

13. Bi-Directional Communication  Communication plan –Methods –Frequency –Internal and external  Inclusive  Strategy  Safe zone

14. Engagement  Teaming –Clinical models –Leadership –Admin support –Patient  Huddling  Patient and family engagement  Change management

15. Engagement: Change Management

17. Care Management  Team-based  Risk-stratified  Protocol-driven  Patient-focused

18.  Process measures  Outcome measures  Balance measures  PDSA fatigue Data (in)Sanity

19. Case Example 1

20. Case Example 2

21. Questions/Comments 21

22. Contact Information Rachel Wallis, MPH Practice Transformation Manager TMF Health Quality Institute Rachel.Wallis@tmf.org 501-815-2948 Emily Glynn Senior Health Services Consultant TMF Health Quality Institute Emily.Glynn@tmf.org 918-706-3896 22