APC Champion: physician/owner with passion and interest in APC; defines vision, value proposition, mission; involved/leads key APC committees. Presents APC measure perfomance and PI activities as a standing Agenda item on practice leadership/Board of Directors meetings.
APC Sponsor: physician/owner with fiduciary responsibility for the practice's business; practice authority to commit to and resource APC initiatives, project plan; responsible for financing and funds flow required for the work of APC implementation and maintenance.
Practice leadership/ owners/Board of Directors work with the Champion and Sponsor to define the APC vision and a formal APC Charter.
Policy: Regular multidisciplinary staff meetings to address HIT issues, improvement, workflow and documentation best practices, and training. Depending on the size of the practice, the HIT Committee may address both EHR/Practice Management System and Data Analytics--or these two domains may be the purview of two committees.
Policy: The PI committee is delegated responsibility for defining all improvement activities, has a multidisciplinary membership (minority of providers), and is chaired/ facilitated by the quality champion (preferably a non-physician).
Policy: Regular, formal all-staff meetings address APC-specific agenda items, share vision (and the Charter), provide education on APC and healthcare policy/trends, seek feedback, routinely share benchmarked performance data and best practices, celebrate top performers. All staff APC meetings are fundamental to building the culture of collaborative accountability.
As defined in the APC Charter, practice leadership/ Board craft and maintain key policies that define practice's APC commitment and standards; structured around the APC Domains and Drivers.
Job Descriptions for all staff within the practice are augmented to include new APC roles & responsibilities required of existing staff positions (e.g., advanced MA's managing Registry outreach) and new APC staff positions (e.g., Care Manager).
Practice policy defines formal structure and process of all meetings including: agenda & agenda setting, minutes, time allocation, facilitation, preparation, accountability, meeting etiquette, representation.
Practice/team APC accountability is defined in the context of the APC Charter and obligates all providers and staff to engage around data, be willing to participate in committees and PI initiatives, work collaboratively within teams and on behalf of practices patients.
Practice Policy states expectations for on-going education of all providers and staff. Education is focused on professional growth within the each staff role, and may include both traditional and APC curricula. Training may be internal or external.
Clinical Team structures designed for patient centered care efficiency and effectiveness; characteristics include Teamlet model (MA:provider >=2:1), top of license distribution of work, proactive team preparation (huddles or Pre-Visit Planning), standard daily meeting times,non-provider meeting facilitation.
Data tools to power proactive team-based care; examples include automated Pre Visit Planning tools, Universal Registries, 2-Factor Risk Stratification reports, performance run charts.
Standardized team-based roles, defined by job descriptions, that maximize top of license capabilities, are powered by standardized care protocols and data, distribute informed, best practice and patient-specific care and are supported by on-going, formal training.
Standardized care protocols to inform advanced teamwork and, in particular, the work of non-licenced team members, addressing population-specific care needs including prevention, screening, behavioral health, and chronic conditions; must be approved by practice leadership.
Documentation of encounter-based care, both by individual team members and across team-based workflows, is informed by clinical decision support and guided by principles of human-centered design to optimize prevention, screening, risk stratification, medication managment (refills, eRx, med rec etc.) and the management of acute & chronic conditions management.
Documentation of the clinical transaction optimized for discrete data capture required for patient-centered best practice care, quality measurement documentation (e.g. eCQMs) and analytics.
Security of PHI and compliance with HIPAA policy and related documentation is supported by access restrictions, EMR PHI transaction utilities in addition to staff ongoing training and compliance monitoring.
IT Security systems include state of the art hardware & software, encryption protocols, monitoring procedures, policies and protocols and are designed and implemented to optimize access security, both local and remote, to practice information systems.
Remote patient access to the practice's EHR system ( Patient Portal) is designed for patient-centered, asynchronous and secure communication with the attributed care team; functionality includes access to the personal health record, medication management and refills, appointment requests, eVisits, patient-generated EHR documentation (e.g., medical history), and notifications by the care team (e.g., appointment reminders, lab and imaging reports etc.).
Regional data integration (Health Information Exchanges and other interface engines) is designed to maximize real-time and secure patient-specific cliical information across all attributed providers of care; electronic exchange of key clinical information between providers should be fully integrated into the EHR, "push-based" and formatted to optimize clinical care (including automated and real-time transition of care alerts of admissions, discharges, ED evaluations).
Practice teams have access to primary source, clinical analytics reports and tools that inform the work of teams in the efficient delivery of evidence-based care; these tools are designed to identify gaps in care specific to empaneled patients (e.g., chronic conditions, screening, prevention); examples include pre-visit planning reports and condition-specific and patient-specific (universal) registries).
Practice teams have access to risk stratification reports that routinely identify subsets of high need/high cost empaneled patients; these reports should draw from 3 data sources including primary source clinical data (EHR), payer/ utilization data and the insights of the clinical team. Patient-specific factors informing the reports, in addition to HCC/RAF scores, should include behavioral health, substance use disorders, high cost/high utilization, poor control/chronic conditions, SDOH, referrals from outside agencies).
The practice and its care teams have access to and and review 4-Part Aim performance reports to inform their quality improvement activities and priorities. These reports must reflect performance over time (run charts) at the provider team and practice levels, include meaningful benchmarks, and allow for customizability (such as addition of annotations, practice-specific goals etc.). Practice ,and its performance improvement team, has capability to create ad hoc and custom clinical reports.
Referral and order monitoring reports are available and routinely used by practice to ensure loop closure and patient follow-up. Reports include timeliness (access)/turn-around-time (especially of documentation and care plan), appropriateness of referral, and network referral efficiency and consistency.
Practice has a defined and ongoing process for analytics engagement including data report validation and iterative improvement.
All analytics report measures are based on national measure standards, such as eCQMs (if possible), and are routinely captured, updated and defined in a practice-specific measure library that is readily accessible by all staff. This measure library includes EHR-specific data entry and workflow best-practices; it also annotates each measure with its refresh rate.
All analytics-based reports based on primary source data are designed to refresh in real-time (or, if this is not possible, same-day).
Practice's structures and systems of routine performance improvement include a multidisciplinary PI committee, including at least one patient, that meets at least monthly and is facilitated/chaired by a PI Champion/SME; a PI agenda that routinely establishes improvement priorities, reviews performance measurement data; and proactively engages the regular participation of a professional Practice Transformation Coach.
The PI Committee (and practice teams) learn and use formal performance improvement and change management methodologies (e.g., MFI, RCA, 5 Whys, Lean) and is accountable for data managment (curation, validation, measure definition etc.), and data tool development and use.
Practice and Team performance is routinely shared with, and feedback solicited from, all members of the staff. Provider, team, and practice performance over time is compared to practice goals and network/regional/ national benchmarks. & transparency (internal, w/patients, network, regional). Lessons learned from PI initiatives are routinely shared and best practices and improvements celebrated.
Practice engages a professional practice transformation coach to provide on-going subject matter expertise, support and mentoring of PI activities, change management and practice systems transformation. These services must be weekly early in the transition from traditional fee-for-service primary care, and at least monthly for more mature APC practice.
APC initiatives, measure performance and PI initiatives are shared with all staff via standardized leadership communication (electronic or paper format and frequency) and meeting venues (e.g., All-Staff mtg, clinical team mtgs). Formalized feedback forums and processes for all staff members; these feedback processes in the daily care of patients include "stop the line" functionality.
The Measure Library defines the scope of performance improvement measurement and includes clinical processes (immunizations, prevention, screening, behavioral health, acute and chronic conditions, patient access, safety, referral management/care coordination and health disparities) and clinical outcomes (behavioral health, acute and chronic conditions, health disparities, safety).
Cost and utilization data for specific patient panels and payers is routinely shared with the practice. These reports identify the total cost of care (per member per month) at the panel-level and identify subsets of high need/high cost patients with potentially avoidable utilization (such as out-of-network referrals or frequent ED use).
Practice's performance improvement initiatives includes patient and family experience of care; practice has a standardized tool for routinely measuring patient & family experience (access, communication, coordination, engagement/SMS) and comparing practice performance against national and/or regional standards.
Performance improvement priorities include routine measurement of the staffs' and providers' experience of care delivery. These measures address purpose and meaning in work, levels of stress, and voice (capacity to contribute to practice changes).
Practice prioritizes and standardizes patient engagement and activation through Self-Management Support, Shared Decision Making; identification of patient preferences & functional/ lifestyle goals; assessment of and adaptation to language/ communication and Health Literacy needs of practice's patient population. Encounter-based Care Plans, especially for high need/high cost patients, are designed to maximize age and health literacy communication and engagement.
Practice routinely solicits and reviews non-structured feedback from patients and their families (e.g., Patient and Family Advisory Council, or PFAC). The PFAC also functions as an important extension of the performance improvement team.
Practice's work to engage patients, particular those that are high need/high cost, requires the care team to understand and respond to the patient-specific "lived environment." To be effective here, the practice must establish Community-Clinical Linkages through integration of its primary care services and non-medical community-based resources and through relationships with community-based health workers or health navigators.
Practice policies define priority and process for patient-care team attribution and panel definitions.
Analytics tools and reports for building panels and assigning patients and care teams include registries (chronic condition, universal, at-risk) and payer-and program-specific panels. Panel design elements are informed by demographic (such as age and sex) and/or acuity characteristics of the practice population with a process for balancing across provider teams.
Practice policies define continuity, access and patient-care team standards including related measures and requirements for monitoring and improvement.
Practice implements, sustains and monitors APC systems of patient-centered access including: open access scheduling (measures include time to third next available appointment, TNA; Portal/ Phone turn-around time); non-visit & alternative care (group visits, home visits) process and standards; later hours and weekend access (office, urgent care, non-visit care); patient portal optimized for care access (asynchronous communication, medical record access, medication refills, appointment management, etc).
Practice policy defines commitment to routine risk stratification of all attributed patients and for the resourcing needed for proactive engagement and management of specific populations of high need/high risk patients.
Practice and care teams integrate the systematic use of a 3-factor risk stratification tool into multidisciplinary care plans and proactive outreach to high need/high cost patients. While optimized for evidence-based clinical care, these care plans are specifically designed to address psychosocial barriers to health & healthcare; the care plans are routinely informed by non-typical members of the care team, such as community health workers, who engage the patient and their family in their "lived environment."
Practice care teams routinely and proactively use registries (including chronic conditions, prevention, screening registries and universal registries) to inform and perform panel-specific patient outreach & and care management for high need/high cost patients and for patients identified with gaps in care.
Care teams routinely use order tracking and follow-up processes for patients requiring lab and imaging studies to ensure completion and management closure.
Practice care teams, including clinical pharmacologists if possible, routinely deliver Medication Therapy Management services focused on high need/high cost and complex patients. These services include medication reconciliation, patient and family education and engagement, and formulary optimization (interactions, cost and effectiveness).
Practice places high priority on access to behavioral health and substance abuse sreening and management integration. This commitment optimally includes behavioral health provier co-location, shared management, collaboration and referral protocols, medical-beavioral health record integration, and care plan collaboration.
Team-based care includes routine behavioral health (e.g., PHQ-9, GAD-7, PC-PTSD) and substance abuse screening & psychosocial needs assessment in care for all patients.
Practice policies define continuity, access and patient-care team standards including related measures and requirements for monitoring and improvement.
Practice develops and maintains formal referral and management relationships with community-based and in-patient behavioral health and substance abuse providers designed to optimize access to evidency-based care (particularly for high need/high cost patients).
Practice commits to team-based approaches to the assessment and remediation of social determinants of health, especially for high need/high cost patients.
Practice develops effective and routine processes for high need/high cost patient evaluation and engagement in their "lived environment" that includes assessment and remediation of psychosocial barriers to health and healthcare.
Practice formalizes the referral and care coordination process across all network referral partners including medical and surgical specialists, outpatient procedural providers, inpatient care facilities (hospitals) and intermediate care facilities (skilled nursing, rehabilitation etc.). Acute care facility transitions (hospitals, emergency departments and urgent care facilities, including admissions and discharges), require automated, real-time alerts of the care team.
The practice-level referral management processes includes standards and measures of performance shared with, and expected, of all network referral partners (see Practice Analytics). These collaborative, mutually negotiated expectations are defined in formal documents ("care compacts") between the APC practice and network referral partners.
Once notified of and informed by an acute care facility regarding a transition of care (summary of care and plan communication) or by a care network referral partner of a completed non-acute care consultation, a formal process is triggered by the practice care team to engage the patient and to ensure appropriate and prompt follow up and care coordination. This process may include phone or asynchronous (patient portal) contact, a follow-up evaluation at the practice, non-visit care, at-home (or, for example, ECF evaluation), and/or engagement of the patient and family by a health navigator.
Practice is a participating member of a regional, integrated delivery network of providers that is organized to deliver high value, patient-centered services to the marketplace. The IDN is led by a dyad-model of executives (business and physician) and is supported by key management and services staff (HIT, PI/practice coaching, analytics, business of practice, contracting, etc.).
As a member of an IDN, the practice receives important support services, those that are critical to the 4-part aim effectiveness and efficiency of the practice, require subject matter/technical expertise uncommon in practices, and have significant economies of scale leveraged over multiple practices. Examples include: HIT (software, hosting, support, training, development, upgrades, enhancements, HIE, best practices; vendor management, due diligence; change control); network referral management system; analytics (software, data tools for measure reporting, performance, team-tools, PI, hosting, support, training, development, upgrades, best practices, vendor management); quality improvement services (practice transformation coaching); value-based payer contracting.
The practice formally participates in network-established 'care compact' agreements with the major specialty and other network providers. These compacts define the mutual expectations for professional collaboration around shared patients including access standards, communication formats, content and timing, care plans, turn-around times, provider roles. Compacts must define the collaborative relationships with commonly-used medical and surgical specialists, tertiary care providers (in-patient facilities, subspecialists) and intermediate care providers/facilities (e.g., rehab, skilled nursing).
Network provides resources and support (internal, shared or contracted) to evaluate and optimize member practice professional business management (e.g., HR, accounts receivable, contracting, strategic planning).
Network engages all providers in a process for measuring and assessing network-based performance of member primary and specialty care providers and other network referral partners (such as inpatient facilities). This process is on-going and includes evaluation of network collaboration, efficiency, access and effectiveness.
Network works with all member practices to establish and maintain a roster of practices that meet minimum criteria of network referral partner performance (the "referral network"). Network provides regular and transparent performance feedback to all member practices and supports a remediation process for practices that fail to meet minimum criteria.
Practice has a critical role in supporting community-clinical linkages through formal collaborative agreement(s) with community-based health navigators that defines the roles and obligations of both the practice and health navigator in the efficient and effective care coordination, and health information communication, across the network and non-medical community-based resources (such as social services, food banks). This agreement includes requirements for health navigation measurement and on-going improvement.
Care teams within the primary care practice identify patients requiring network referral partner services (informed by their patient-provider relationships, during the process of care and by risk stratification tools) and coordinate with community-based resources (such as health navigators and/or community health workers) to ensure efficient and effective healthcare system navigation.
Health Navigation: community-based. Community-based Health Navigators are key members of the primary care team and ensure efficient and effective care coordination for patients requiring care from network referral partners and non-medical community resources. The health navigator's responsibilities also include the identification of and relationship building with key community-based resources.
Practice negotiates (either directly or through IDN payer services) value-based payer contracts that explicitly support the incremental costs of advanced primary care staff, infrastructure and services and incentivizes and rewards the practice for the delivery of high value care (triple-aim performance).
The strategic business plan of the practice (and, if applicable, the IDN) is designed to successfully transition from FFS to value-based revenue.
Practice participates in non-traditional models for healthcare services payment including direct-to-patient and/or direct-to-employer contracts (such as direct primary care, employer-self-insured contracts).
Value-based payer contract funds flow revenue (non-FFS, including per member per month management fees, quality/ efficiency performance incentives) is allocated by practice policy to support new staff roles (e.g. health navigator, extra MA's), providers (e.g. BH), other APC-specific overhead expenses and incentive payments to providers and care teams. In fully capitated contracts, funds flow revenue also supports routine operations, overhead & expenses, and staff and provider salaries and benefits.
When practices are participating members of integrated delivery networks and the network manages payments (under physician board direction) from value-based contracts, funds flow revenue is allocated to support network APC-specific resources & non-staff services provided to member practices (such as shared analytics and practice coaching services).