Building Blocks

ISP practice transformation milestones are organized within a well-recognized framework, Bodenheimer’s “10 Building Blocks of High-Performing Primary Care,” with some modifications to reflect the ISP program’s focus on Medicaid Alternative Payment Model.

These milestones have been updated to create a more structured timeline for progression, and ensure alignment between practice transformation work and the advanced payment models supporting them. The milestones are divided into phase 1, 2 and 3; many phase 1 milestones involve developing infrastructure to start a new process with a corresponding phase 2 and 3 milestone to fully implement and scale the process.

Building Block 1: Engaged Leadership

GOAL: Practice leadership supports and engages in quality improvement and change management.

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Building Block 2: Data Driven Quality Improvement (QI)

GOAL: Practice extracts and uses clinical quality measure (CQM) data and sound QI methods to improve care.

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Building Block 3: Empanelment

GOAL: Practice manages panels to optimize access, continuity and business operations.

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Building Block 4: Team-Based Care

Goal: Practice care team uses shared operations, workflows and protocols to facilitate collaboration and to improve quality and utilization metrics.

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Building Block 5: Patient and Family Engagement

GOALS; Practice routinely uses evidence based shared decision aids and self management support tools.

Practice has established mechanisms for patients to provide input and feedback, including on transformation activities and progress.

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Building Block 6:  Population Management

GOAL: Practice uses population-level data to manage care gaps and develop and implement care management plans (including behavioral health) for targeted high-risk patients and families.

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Building Block 7: Continuity of Care

GOAL: Practice optimizes continuity of care for empaneled patients while preserving access.

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Building Block 8:  Access

GOAL:  Practice provides prompt access to care, including behavioral health care, using traditional methods and new technologies.

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Building Block 9: Comprehensiveness and Care Coordination

GOAL:  Practice provides comprehensive primary care services, including behavioral health.

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Building Block 10:  Value-based Contracting

Goal:  Practice succeeds in their value based contracts by reducing total cost of care while improving quality for their patients.

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Optional Focus: Addressing Social Needs of Patients

GOAL:  Practice routinely assesses patients for social needs and links them to appropriate community resources.

There are a variety of actions that healthcare settings can take to incorporate social needs into medical practice. These activities fall into five categories:

Awareness: Activities that identify the social risks and assets of defined patients and populations.

Adjustment: Activities that focus on altering clinical care to accommodate identified social barriers.

Assistance: Activities that reduce social risk by providing assistance in connecting patients with relevant social care resources.

Alignment: Activities undertaken by health care systems to understand existing social care assets in the community, organize them to facilitate synergies, and invest in and deploy them to positively affect health outcomes.

Advocacy: Activities in which health care organizations work with partner social care organizations to promote policies that facilitate the creation and redeployment of assets or resources to address health and social needs.

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Optional Focus: Substance Use Disorder

GOAL:  Practice systematically screen for substance use and provides outpatient substance use disorder treatment for appropriate patients.

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Optional Focus: Telehealth

GOAL:  Practice effectively delivers and gets reimbursed for telehealth services, including behavioral health, delivered to patients.

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