Practice Leadership & Advanced Teamwork

Advanced Primary Care Leadership

Formalized APC Committees/Meetings

APC Policies

ATW Structure and Processes

HIT Optimization & Analytics

Structure, Functionality & Support

Primary Source Clinical Data

Data Quality

Learning Organization

Learning Organization Structure/Processes

Performance Measurement

Provider & Team Vitality

Patient & Family Engagement

Patient & Family Activation

Population Health Management


Access and Continuity

Risk Stratification

Panel Management & Outreach

Behavioral Health Integration

Social Determinants of Health

Care Transitions & Referral Coordination

Community & Network Integration

Integrated Delivery Network

SCP Provider Performance

Community Clinical Linkages

Value-Based Business Model

Value-Based and Alternative Payment Contracting

Value-Based Contract Funds Flows