Caring for patients in value-based care
A value-based approach can increase access to and continuity of care for your patients.
Value-based care shifts the focus from volume to results. Instead of paying only for office visits, it rewards better outcomes and supports care coordination. This shift gives you more flexibility. You can focus on long-term patient relationships, team-based problem solving and proactive outreach that prevents health crises.
Day to day, value-based care shows up in different ways. Some physicians reduce panel sizes. Others use care managers to stay in touch between visits or adjust their schedule to make access more predictable. With the right data, it’s easier to spot who needs a check in and follow through.
Behavioral health becomes part of the norm. Referrals stay on track. And chronic conditions are easier to manage, which means fewer emergency visits and less stress for your team.
To help you get there, the American Academy of Family Physicians (AAFP) offers practical tools, resources and guidance. Whether you’re improving access, strengthening continuity or integrating behavioral health, you don’t have to do it alone.
Caring for patients: Free CME for AAFP members
Access and continuity
Build trust with timely visits and consistent teams
When access and continuity work, everything gets easier. There are fewer gaps and avoidable visits while patient trust grows. Anchor each patient to a primary clinician and team, make it simple to get timely care in person or virtually, and set clear rules for same-day requests and inbox work. Add brief previsit planning and close the loop after each encounter so your panel stays balanced and patients know exactly where to turn.
Use these ideas and tools to make the most of your panel.
Resources
Panel size is just a number: Use a rubric that considers case mix and productivity when you open or close panels. Panel size decisions
The right-sized patient panel: Calculate and adjust panel size with a repeatable process and a useful spreadsheet. Panel size tools
Access to care topic collection: Browse strategies for same-day care, scheduling, no-show reduction and more. FPM topic collection
Care management and coordination
Organize outreach, close gaps and share the workload
Care management turns data into action and keeps care moving between visits. Start with a small registry and a few patients who need extra help. Decide who reaches out, what you will cover and how you will document, then make brief check-ins part of routine care. By focusing on closing loops and removing barriers, each visit starts further ahead. Track a couple of outcomes to show progress and expand the model when your team is ready.
Access these resources to improve patient care and team coordination.
Resources and tools
Care management in the medical home: Learn what care management is and how to identify patients who benefit most. Care management overview
Care management toolkits: Integrate Medicare chronic care management and transitional care management with ready-to-use tools. Chronic care toolkit and Transitional care toolkit
Risk algorithm and rubric: Access practical tools to stratify risk and target outreach. Risk algorithm and Risk rubric
Care management financials: Download these tools to make a simple business-case presentation and calculate return on investment. Business deck and Return on investment calculator
Team strategies for improving risk adjustment: Get tips on hierarchical condition category coding and how to get the whole team on board. Watch the video
Bright Spots Report on Medicare Advantage: Learn from case studies featuring successful primary care models in Medicare Advantage. Read the report
FPM Care management topic collection: Explore real-world articles on outreach, referral loops and using data to close gaps. FPM topic collection
Behavioral health integration
Screen, refer and follow up with one team
Integrated behavioral health brings mental health into everyday primary care so patients get help sooner, in fewer steps. Start with routine screening, a warm handoff and a clear follow-up plan. Build simple shared workflows. Use same-day consults, team huddles, shared notes and closed-loop referrals so no one falls through the cracks.
Use these resources to help you train your team, standardize tools and track outcomes.
Resources and tools
Behavioral health integration CME videos: Use the AAFP’s on-demand education to support integrated workflows and better outcomes. On-demand CME
Behavioral health integration implementation resources: Access tools and a video on how to use Patient Health Questionnaire-9 in everyday care. Implementation resources
Behavioral health topic collection: Get collaboration tips, scheduling models and examples from practices like yours. FPM topic collection
