Building on Change

Transforming Your Practice

Planned Care and Population Health

• Implement team-based care.
• Learn about population health management.
• Implement planned care for chronic and preventive services.
• Implement patient care and action plans.

Learn More:

• Designate Your Planned Care Team
• An Organized Approach to Chronic Disease Care - FPM  Journal
• Population Health Curriculum (www.graham-center.org)

Care Management

• Risk-stratify your empaneled patient population.
• Provide appropriate care based on patient needs and background.

Learn More:

• AAFP’s Risk-Stratified Care Management Rubric

Patient and Caregiver Engagement

• Prepare to implement patient self-management support.
• Assess the self-management skills of patients and caregivers.
• Use motivational interviewing to coach patients.
• Investigate ways to harness input from patients and families (e.g., focus groups, participation in practice improvement projects, patient and family advisory councils).

Learn More:

• Engaging Patients in Collaborative Care Plans - FPM Journal
• Encouraging Patients to Change Unhealthy Behaviors With Motivational Interviewing - FPM Journal
• Using Motivational Interviewing to Promote Healthy Weight - FPM Journal

Comprehensiveness and Coordination

• Coordinate and monitor care transitions across the medical neighborhood.
• Connect your practice digitally to the medical neighborhood using certified EHR technology (CEHRT) and secure Direct Messaging.

Learn More:

• Transitional Care Management: Why Bother? - FPM Journal
• AAFP Transitional Care Management Toolkit
• Finding the Bright Spots in Value-Based Care - FPM Journal

Quality Improvement

• Identify opportunities and apply QI methods to improve performance.
• Develop a culture of patient safety and address safety concerns.

Learn More:

• Addressing Ambulatory Patient Safety in Your Practice - FPM Journal