Getting Started

Transforming Your Practice

Planned Care and Population Health

• Understand the basics of team-based care.
• Define team member roles for team-based care.
• Train and cross-train staff on team-based care.

Learn More:

• Team-Based Care: Saving Time and Improving Efficiency - FPM Journal
• A Team-Building Model for Team-Based Care - FPM Journal
• Sample Huddle Agendas

Care Management

• Assess the medical needs of your patient population and your practice’s readiness to address these needs.
• Learn about risk-stratified care management.
• Investigate various models for providing care management in your practice.

Learn More:

• AAFP’s Risk-Stratified Care Management Rubric
• Bright Spots in Care Management (www.graham-center.org) 

Patient and Caregiver Engagement

• Assess patient population for culture, language, barriers, and psychosocial needs.
• Conduct patient satisfaction surveys and act on the results.
• Establish a care plan template and process for including patients as active participants in the care team.

Learn More:

• Seven Principles for Improving Service and Patient Satisfaction - FPM Journal
• Engaging Patients in Collaborative Care Plans - FPM Journal

Comprehensiveness and Coordination

• Create a team to oversee care transitions.
• Determine the approach and processes your practice will use to monitor and follow-up with transitions of care.
• Build relationships with community resources.

Learn More:

• The Benefits of Using Care Coordinators in Primary Care: A Case Study - FPM Journal

Quality Improvement

• Learn about the basic principles of QI.
• Learn about patient safety basics and assess your practice.
• Form a team to implement continuous quality improvement.

Learn More:

• Basics of Quality Improvement
  
• Quality Measures