Sustaining Success

Transforming Your Practice

Planned Care and Population Health

• Work with your vendor to understand your EHR population health capabilities.
• Select and use patient registries for population health management.

Care Management

• Integrate evidence-based guidelines into your risk-stratified care management levels and care management plans.

Learn More:

• Bright Spots in Care Management (www.graham-center.org)

Patient and Caregiver Engagement

• Engage patients in shared decision making.
• Offer health coaching to patients.
• Conduct periodic patient focus groups.
• Establish a patient and family advisory panel.
• Implement patient home monitoring for chronic conditions.

Learn More:

• Shared Decision Making: The Need For Patient-Clinician Conversation, Not Just Information (www.healthaffairs.org)
• Shared Decision Making: Examining Key Elements And Barriers To Adoption Into Routine Clinical Practice (www.healthaffairs.org)
• Health Coaching: Teaching Patients to Fish - FPM Journal
• Patient Advisory Councils: Giving Patients a Seat at the Table - FPM Journal

Comprehensiveness and Coordination

• Use performance measures to evaluate and improve care transition processes.
• Expand information sharing capabilities by linking to regional health information exchange organizations (HIO).

Learn More:

• Technology Tools and Trends for Better Patient Care: Beyond the EHR - FPM Journal

Quality Improvement

• Set aside time for QI, hold regular meetings with QI team and entire staff to discuss results.
• Display quality and patient safety progress for staff and patients.

Learn More:

• Quality and Safety Topic Collection - FPM Journal