A support program for family medicine, internal medicine, pediatric, and OB/GYN practices who serve Medicaid patients.
The ISP Implementation Guide is a resource for participating primary care practices to succeed in creating an advanced medical home. This guide provides a description of the ISP Building Blocks and concrete milestones to achieve the goal for each Building Block.
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.
GOAL: Practice routinely incorporates inclusivity and health equity into practice innovation efforts.
MILESTONES:
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. https://doi.org/10.1186/1748-5908-8-60
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. https://doi.org/10.1186/1472-6963-13-441
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:
GOAL: Practice leadership supports and engages in quality improvement and change management.
MILESTONES:
Action Items
Practice Facilitator Methodology:
Confirm the communication to practice staff and that there is a process in place for evaluating changes.
Action Items:
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.
Action Items:
Practice Facilitator Methodology:
Confirm recognition and rewards are being considered in the clinic.
GOAL: Practice extracts and uses clinical quality measure (CQM) data and sound QI methods to improve care.
MILESTONES:
Action Items:
Practice Facilitator Methodology:
Confirm and document improvement team meetings in monthly field notes
Action Items:
Practice Facilitator Methodology:
Confirm and document practice using CQM data in QI efforts.
Action Items:
Practice Facilitator Methodology:
Confirm that performance feedback is provided to providers.
Action Items:
Practice Facilitator Methodology:
Confirm and document practice data driven QI efforts.
Action Items:
Practice Facilitator Methodology:
Confirm and document that the practice is using QI to implement improvements.
Action Items:
Practice Facilitator Methodology:
Confirm practice implementation of protocols and workflows related to three chosen quality measures.
GOAL: Practice manages panels to optimize access, continuity and business operations.
MILESTONES:
Action Items:
Practice Facilitator Methodology:
Confirm practice has implemented a process of assigning patients to PCPs/care teams.
Action Items:
Practice Facilitator Methodology:
Confirm empanelment of 90% of patients.
Action Items:
Practice Facilitator Methodology:
Confirm review and reconciliation of payer attribution lists.
Action Items:
Practice Facilitator Methodology:
Confirm practice is able to manage panels and optimize patient needs.
GOAL: Practice care team uses shared operations, workflows and protocols to facilitate collaboration and to improve quality and utilization metrics.
MILESTONES:
Action Items:
Practice Facilitator Attestation Methodology:
Confirm review of at least two job descriptions. Practice can attest that others are in place.
Action Items:
Examples may include:
Practice Facilitator Methodology:
Confirm practice implementation of team-based care strategies.
Action Items
Practice Facilitator Methodology:
Confirm review of the standardized tool with the practice or practice's quality improvement team.
Action Items:
Practice Facilitator Methodology:
Confirm implementation and/or maintenance of team-based care model.
Action Items:
Practice Facilitator Methodology:
Confirm practice implementation of team-based care strategies.
Action Items:
Practice Facilitator Methodology:
Confirm practice is implementing QI into daily practices.
Action Items:
Practice Facilitator Methodology:
Confirm practice is onboarding staff with an understanding their role in QI and providing professional development to sustain QI efforts.
Action Items:
Practice Facilitator Methodology:
Confirm practice has a system in place.
Action Items:
Practice Facilitator Methodology:
Confirm practice reassesses team experience annually.
Action Items:
Practice Facilitator Methodology:
Confirm in QI team meetings that practice is functioning at top capacity.
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.
MILESTONES:
*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:
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.
Action Items:
Practice Facilitator Methodology:
Confirm practice implementation of PFAC meetings.
Action Items:
Practice Facilitator Methodology:
Confirm the use of patient experience survey and the Incorporation of results into practice.
Action Items:
Practice Facilitator Methodology:
Confirm practice implementation of decision aids or self-management tools.
Action Items:
Practice Facilitator Methodology:
Confirm practice implementation of quarterly PFAC meetings.
Action Items:
Practice Facilitator Methodology:
Confirm practice is using practice experience survey information in a meaningful way to inform QI.
Action Items:
Practice Facilitator Methodology:
Confirm practice implementation of at least two decision aids or self-management tools.
See 5.1.2 and 5.2.2 for additional support on PFAC.
Action Items:
Practice Facilitator Methodology:
Confirm practice implementation of PFAC meetings. Periodically review membership and longevity on the board.
Dartmouth-Hitchcock: Center for Shared Decision Making
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
Patient, Family and Stakeholder Engagement
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.
MILESTONES:
Action Items:
Practice Facilitator Methodology:
Confirm practice identification of a risk stratification methodology and that the practice has fully accomplished the milestone.
Action Items:
Practice Facilitator Methodology:
Confirm practice has identified strategy to address gaps in care.
Action Items:
Practice Facilitator Methodology:
Confirm practice is proactively addressing care management through strategies to identify and care for high risk populations.
Action Items:
Practice Facilitator Methodology:
Confirm the practice has implemented a workflow for care management and tracking outcomes.
Action Items:
Practice Facilitator Methodology:
Review practice data and confirm target is met.
Action Items:
Practice Facilitator Methodology:
Tracking the care plan and the practice has fully accomplished the milestone.
GOAL: Practice optimizes continuity of care for empaneled patients while preserving access.
MILESTONES:
Action Items:
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.
Action Items:
Practice Facilitator Methodology:
Confirm practice has tried one strategy to improve continuity of care and document in field notes.
Action Items:
Practice Facilitator Methodology:
Confirm that practice has system in place and improving continuity of care.
GOAL: Practice provides prompt access to care, including behavioral health care, using traditional methods and new technologies.
MILESTONES:
Action Items:
Practice Facilitator Methodology:
Confirm practice has a report for appointment availability and patient experience survey.
Action Items:
Practice Facilitator Methodology:
Confirm that patients have 24/7 access to practice representative with EHR access.
Action Items:
Practice Facilitator Methodology:
Confirm practice has referral sources and ability to evaluate and make changes.
Action Items:
Practice Facilitator Methodology:
Confirm that practice has implemented and maintained at least one extended access service for patients.
Action Items:
Practice Facilitator Methodology:
Confirm the practice has established a collaborative agreement with specialty groups that share in the care of their patients.
Action Items:
Practice Facilitator Methodology:
Confirm practice is reviewing specialty care access at least annually and seeking new collaborative care agreements with appropriate specialty partners.
GOAL: Practice provides comprehensive primary care services, including behavioral health.
MILESTONES:
Action Items:
Practice Facilitator Methodology:
Confirm practice has a completed an assessment of services and a plan has been established.
Action Items:
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.
Action Items:
Practice Facilitator Methodology:
Confirm practice using data to improve behavioral health outcomes.
Action Items:
Practice Facilitator Methodology:
Confirm practice has performed assessment and has contacted RHC.
Action Items:
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.
Action Items:
Practice Facilitator Methodology:
Confirm practice has at least one collaborative care agreement with high cost/high volume specialty provider.
Action Items:
Practice Facilitator Methodology:
Confirm the practice has assessed changes in the clinic.
Actions Items:
Practice Facilitator Methodology:
Confirm availability of behavioral health services to patients.
Action Items:
Practice Facilitator Methodology:
Confirm presence of tracking data and using data to improve BH outcomes.
Action Items:
Practice Facilitator Methodology:
Confirm the development of at least one collaborative agreement with at least one community behavioral health provider.
Action Items:
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.
Action Items:
Practice Facilitator Methodology:
Confirm practice has at least two collaborative care agreements.
Action Items:
Practice Facilitator Methodology:
Confirm practice implementation of protocols.
Action Items:
Practice Facilitator Methodology:
Confirm practice using data to improve behavioral health outcomes.
Action Items:
Practice Facilitator Methodology:
Confirm a plan for bidirectional data sharing completed with at least one behavioral health provider.
Action Items:
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.
Action Items:
Practice Facilitator Methodology:
Confirm annual review has been completed and practice can and will make changes if necessary.
American College of Physicians: High Value Care Coordination Toolkit
AHRQ Integrating BH and Primary Care Playbook
Care Collaborative Agreement Facilitation Guide
Collaborative Care Implementation Guide
Coordinating Care in the Medical Neighborhood Critical Components and Available Mechanisms
Financially Sustaining Behavioral Health Integration
PCPCC Colorado Primary Care Specialty Care Compact
Practical Approaches for Achieving Integrated BH Care in PC Settings
SAMSHA Standard Framework for Levels of Integrated Care
GOAL: Practice succeeds in their value based contracts by reducing total cost of care while improving quality for their patients.
MILESTONES:
Action Items:
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
Action Items:
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
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:
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 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.
Action Item:
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.
Action Items:
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.
Action Items:
Practice Facilitator Methodology:
Practice can articulate what items in the budget need to be adjusted up or down for VB contracts
Action Items:
Practice Facilitator Methodology:
Confirms practice has a vetted value proposition that has been used in payer negotiation meetings.
Action Items:
Practice Facilitator Methodology:
Confirm practice has improved one metric.
Action Items:
Practice Facilitator Methodology:
Confirm the practice has/does share financial data transparently and uses tools to make financial decisions.
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.
MILESTONES:
Action Items:
Practice Facilitator Attestation Methodology:
Confirm practice has selected a method and created an action plan for assessing needs and identifying priority social need(s).
Action Items:
Practice Facilitator Methodology:
Confirm practice assessment of social care resources. This can include the use of formal external assessments of such resources.
Action Items:
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.
Action Items:
Practice Facilitator Methodology:
Confirm practice has developed community partnerships.
Action Items:
Practice Facilitator Methodology:
Confirm the practice is working with the community and regional health connectors.
Action Items:
Practice Facilitator Methodology:
Confirm practice is screening for additional social need.
Action Items:
Practice Facilitator Methodology:
Confirm practice is working with partners and using bi-directional data sharing.
Action Items:
Practice Facilitator Methodology:
Confirm practice is advocating for resources.
Accountable Health Communities Health Related Social Needs Screening Tool (AHC HRSN)
Aunt Bertha (resource directory)
Community health improvement plans
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
GOAL: Practice systematically screen for substance use and provides outpatient substance use disorder treatment for appropriate patients.
MILESTONES:
Action Items:
Practice Facilitator Methodology:
Practice has screening tool selected and workflow planned.
Action Items:
Practice Facilitator Methodology:
Confirms practice is screening patients.
Action Items:
Practice Facilitator Methodology:
Confirm practice has trained the team to provide treatment for AUD and OUD.
Action Items:
Practice Facilitator Methodology:
Confirm practice has a documented process for connecting patients to resources.
Action Items:
Practice Facilitator Methodology:
Confirms practice has at least one provider who can provide MAT.
GOAL: Practice effectively delivers and gets reimbursed for telehealth services, including behavioral health, delivered to patients.
MILESTONES:
Action Items:
Practice Facilitator Methodology:
Practice Facilitator verifies that practice has telehealth available to patients.
Action Items:
Practice Facilitator Methodology:
Confirms practice has completed assessment and has adequate resources.
Action Items:
Practice Facilitator Methodology:
Confirms practice can provide acute telehealth visits.
Action Items:
Practice Facilitator Methodology:
Confirms practice is able to complete primary care visits using telehealth.
Action Items:
Practice Facilitator Methodology:
Confirms practice is receiving payment for telehealth services from payers.
Action Items:
Practice Facilitator Methodology:
Confirms practice has a workflow for telehealth services.
Action Items:
Practice Facilitator Methodology:
Confirms practice has software available.
Action Items:
Practice Facilitator Methodology:
Confirms practice can provide prevention telehealth visits.
Action Items:
Practice Facilitator Methodology:
Confirms practice can provide overdue chronic are services.
Action Items:
Practice Facilitator Methodology:
Confirms practice is receiving payment from Medicare and Medicaid.
Action Items:
Practice Facilitator Methodology:
Confirms practice has software available and in use.
Action Items:
Practice Facilitator Methodology:
Confirms practice can provider chronic care visits to patients.
Action Items:
Practice Facilitator Methodology:
Confirms practice has completed telehealth visits for recently discharged patients.
Action Items:
Confirms practice is receiving payment from commercial payers.
CU Anschutz
Academic Office One
12631 East 17th Avenue
Aurora, CO 80045