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.
Practice leadership incorporates health equity into quality improvement initiatives. (Related to BB1 – Engaged Leadership)
Health equity is considered and included in practice AIM statements and goals.
Considerations to measure elements of health equity are included in PDSA cycles.
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.
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)
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.
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.
Practice includes consideration of patient demographics and health equity in quality improvement efforts. (Related to BB2 – Data Driven Quality Improvement)
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.
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.
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)
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.
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.
Practice implements a team-based communication strategy to improve engagement of all team members. (Related to BB4 – Team-Based Care)
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.
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.
Practice develops and provides individualized professional development for all staff. (Related to BB4 – Team-Based Care)
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.
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)
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.
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.
Practice assesses the inclusivity of the practice through items on their patient experience survey. (Related to BB5 – Patient and Family Engagement)
Annual patient experience survey includes questions that assess inclusivity.
Practice is intentional about acting upon recommendations arising from patient experience survey.
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)
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.
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.
GOAL: Practice leadership supports and engages in quality improvement and change management.
GOAL: Practice extracts and uses clinical quality measure (CQM) data and sound QI methods to improve care.
GOAL: Practice manages panels to optimize access, continuity and business operations.
GOAL: Practice care team uses shared operations, workflows and protocols to facilitate collaboration and to improve quality and utilization metrics.
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.
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.
GOAL: Practice optimizes continuity of care for empaneled patients while preserving access.
GOAL: Practice provides prompt access to care, including behavioral health care, using traditional methods and new technologies.
GOAL: Practice provides comprehensive primary care services, including behavioral health.
GOAL: Practice succeeds in their value based contracts by reducing total cost of care while improving quality for their 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.
GOAL: Practice systematically screen for substance use and provides outpatient substance use disorder treatment for appropriate patients.
GOAL: Practice effectively delivers and gets reimbursed for telehealth services, including behavioral health, delivered to patients.