Criteria for Excellence | Appendix 1: Principles grounding the family medicine practice

Build a family medicine practice grounded in accessible, comprehensive and coordinated care.

Understand the community context for family medicine care

Family physicians remain committed to preventing disease, treating illness, and promoting the health of individual patients and communities, and these goals are being highlighted in the move to value-based payments. Neutze et al2 note:

Current challenges with widening gaps of [inequity] remain rooted in our inability to address the underlying driving systems at the community level.7,8 Training in community settings that includes public and population health provides the adaptability required to respond to a variety of our patients’ needs.9 Longitudinal and experiential models of training lend themselves to greater appreciation for cultural competencies and social drivers of health, especially in [underserved] settings and areas with significant health care disparities.10

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Residents should be given opportunities to integrate community and public health into their practice during family medicine residency training.11 Ensuring that residents attain the right knowledge, skills, and attitudes requires intentional changes to the training setting, didactic content, and overall experience. In particular, curricula around social determinants of health must be improved.12

The community served has a direct impact on the practice environment and the trajectory of trainees. Regardless of whether a training location is in a rural, urban, or suburban area, the process by which a practice grounds itself “in place” influences training. A Program of Excellence should actively engage in defining its community and strategize how it can provide care to best serve that community.

  • Folsom Group. Communities of solution: the Folsom Report revisited. Ann Fam Med. 2012;10(3):250-260.
  • Gotler RS, Green LA, Etz RS. What 1966 can teach us about the future of primary care: the case for communities of solution​. Milbank Q Opinion. Published June 10, 2020. Accessed October 26, 2022.
  • Longlett SK, Kruse JE, Wesley RM. Community-oriented primary care: historical perspective. J Am Board Fam Pract. 2001;14(1):54-63.
  • National Commission on Community Health Services. Health is a community affair. Harvard University Press; 1967.
  • Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457-502.
  • Westfall JM. Cold-spotting: linking primary care and public health to create communities of solution. J Am Board Fam Med. 2013;26(3):239-240.

Improve access to primary care in the residency practice

Access to primary care has been associated with lower cost of care and improved health outcomes, and it is a major driver in patient satisfaction. In residency clinics, access to care is influenced by complex dynamics such as resident and faculty visit numbers, panel size, urgent needs, and scheduling. A Program of Excellence should recognize the broad scope of practice and the range of needs from the patient perspective and should ensure that services are readily available via a variety of methods.

Key aspects of establishing improved access include the overall number of care opportunities provided, the facility in which they are provided, measurement and control of the panel size, and the size and function of capacity-enhancing teams established within the practice.

To provide person-centered, prompt access to care, practice leadership must develop systems to facilitate follow-up access, urgent same-day access, night and weekend access, and phone access. Excellence in the practice management function cannot be realized without fully utilizing available tools within the practice’s electronic health record (EHR) and scheduling systems.

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Core tenets of accessible care include the following:

  • Equity promotion: Care is equitable and free of discrimination.
  • Cultural competency: Care is provided in a context of cultural competency and cultural humility and takes patients’ health literacy into account.
  • Care integration: Availability, quality, and integration of health care services is ensured throughout the health system. Practices demonstrate this by doing the following:
    • Actively measuring the quality of referred care
    • Maintaining ongoing communication with any patient who is referred for significant services
    • Having early in-person or phone contact with hospitalized patients and/or their families
    • Demonstrating willingness and availability to intervene in the referred care process
    • Communicating closely with the preferred health care professional(s) to maximize comprehensiveness and efficiency of care
  • Person-centered and relational approach: The patient-physician partnership results in decisions that respect patients’ wants, needs, and preferences. Patients receive the education and support they need to make decisions regarding their own care.

Family medicine residency practices are in a key position to eliminate barriers to access. A Program of Excellence models the ideal medical practice by utilizing multimodal communication, providing transparency of medical records, and taking a person-centered approach to appointment scheduling.

Technology should be utilized in a manner that enhances the patient and clinician experience. This should result in enhanced personal relationships, clarity of medical plans, and convenience in accessing services.

Communication barriers can be partially eliminated through use of a multimodal path that allows for contact between the patient and the practice by phone, in person, through portals, and through internet accessibility.

The EHR system can be a key tool in the provision of care, but it can also be a barrier. A Program of Excellence is only able to achieve the Quadruple Aim by continually refining the efficiency of EHR use.

EHRs do have many benefits. They enable clinicians to better document clinical encounters, actively engage patients, and follow patients longitudinally. However, there are also many barriers to EHR implementation. EHR functionality needs to be improved to support continuity, comprehensiveness, and patient centeredness, particularly for primary care.

Aside from EHR functionality, the biggest problem is the lack of timely access to individual and population data. In the residency training setting, being able to transfer information efficiently across systems and to the primary care outpatient record is critical for achieving better care at lower costs.

Scheduling is a critical part of ensuring that patients can access clinical care in a timely manner. Additional complexities come into play when building an optimal clinical environment that incorporates residents, core faculty physicians, and faculty functioning as part-time clinicians.

Resident schedules must balance the priorities of clinic and inpatient settings. Scheduling residents in the clinic regularly, predictably, and far in advance with short intervals between clinic times maintains stable teams and provides more predictable patient continuity.

A Program of Excellence can best meet the varying needs of its patients by incorporating the following key elements of advanced appointment scheduling:

  • Patients have multiple access paths to make appointments.

  • Assistance is available to determine the urgency of the appointment.

  • Ideally, patients are able to make appointments with an appropriate team member when desired.

  • Patients have access to care and information after hours (i.e., 24/7).

  • Nontraditional care appointments, such as group visits, are offered.

  • Nontraditional care appointments, such as group visits, are offered.

  • Resident schedules are made far in advance so that clinics can plan their work.

  • Inpatient services do not control resident schedules. Schedules are worked out collaboratively between the clinic and the hospital, and the clinic’s needs are taken seriously.

  • Resident presence in the clinic is predictable so that teams can function smoothly.

  • Chang CH, Stukel TA, Flood AB, et al. Primary care physician workforce and Medicare beneficiaries' health outcomes [published correction appears in JAMA. 2011;306(2):162]. JAMA. 2011;305(20):2096-2104.
  • Forrest CB, Starfield B. The effect of first-contact care with primary care clinicians on ambulatory health care expenditures. J Fam Pract. 1996;43(1):40-48.
  • Sinsky CA, Willard-Grace R, Schutzbank AM, et al. In search of joy in practice: a report on 23 high-functioning primary care practices. Ann Fam Med. 2013;11(3):272-278.

Provide comprehensive, whole-person family medicine care

The family medicine residency practice must provide care services for people of all ages and for all health conditions within the medical home. Primary care physicians coordinate the complex chronic care of patients who often have multiple morbidities.

Furthermore, trends in chronic illness in relation to current public and community needs offer a broader role for primary care physicians in areas including mental health, obesity, addiction, chronic infections, palliative care, telehealth, and expanded outpatient care beyond the walls of the practice.

For a Program of Excellence, comprehensiveness goes beyond just delivering high-quality care for both prevention and chronic disease. Residents must practice in a setting that recognizes the evolving health needs within the community served.

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A Program of Excellence should offer the following comprehensive services:

  1. Wellness promotion and disease prevention programs and services
    1. These should be available throughout the office and should include exercise, nutrition, preventive care, and mental health programs.
    2. Appropriate disease screening and testing procedures should be present.
  2. Planned chronic disease management
    1. The program should integrate evidence-driven, person-centric chronic disease management for its patients.
      1. The practice should promote self-management with attention to health literacy and cultural competency. This may be manifested through multimodal patient communications, group visits, home care and monitoring, and use of self- management resources.
      2. The practice should offer support for physicians and patients using clinician education, consultation support, and patient guidelines with personalized targets and recommendations.
      3. The practice’s delivery system should emphasize a team approach to patient care that includes planned visits with proactive follow-up; a clear set of performance goals; team members who possess appropriate training/expertise; a means to identify all patients in the practice who could benefit from team management; creative use of resources for efficient and effective care (e.g., group visits, web-based services); and ways of measuring and tracking the team’s performance.
      4. The practice should utilize clinical information systems (e.g., registries) that provide clinical prompts for tracking patients with certain conditions; offer mechanisms for tracking performance of physicians and teams; and provide risk- factor analysis to predict health outcomes.
      5. The practice should assess self-management needs of patients and match them to appropriate community resources to foster improved outcomes.
      6. The practice should coordinate consultation and referral of patients within the health care organization by facilitating communication.
  3. Procedures and ancillary services
    1. The medical home should provide a variety of procedures and ancillary services that can be safely performed to improve patient outcomes in the practice.
  4. Behavioral health services
    a. Many patients have comorbid conditions, including mental health disorders, and primary care remains the point of first contact for these patients.

Data-driven improvement is a continual process undertaken by the best practices. Key features include transparent data, meaningful performance measures, clearly defined improvement goals and structures that allow residents and teams to participate.

  • Robust, clear data are available and transparent across clinic, team and clinician (including resident) levels.

  • Data include a range of clinical, operational, cost, patient, and staff experience,
    including resident experience.

  • Practice improvement goals related to the metrics are clearly defined.

  • Measures are made meaningful and actionable for residents and teams.

  • Meeting structures exist for discussing and improving performance.

  • Resident schedules prioritize participation.

Principles of QI and patient safety include the following:

  • Evidence-based care

  • Physician competency in providing care

  • Focus on patient safety

  • Outcome analysis and a system for monitoring variance

Patient safety can be emphasized by holding regular morbidity and mortality conferences that utilize root-cause analysis, if appropriate; credentialing physicians for competency; and reporting unusual occurrences. Outcomes can be analyzed through key indices, such as quality of evidence-based medical care, patient satisfaction, access to care, practice efficiency, staff morale, and practice finances. The system can be monitored by reviewing quality measures, improved outcomes, and patient/learner satisfaction.

In the residency practice, each resident should be involved with a care committee and should design and implement at least one patient safety or QI project during their three years in the residency. This will emphasize the importance of the principles of QI and patient safety. Residents should participate in discussions with team members about access, availability,
patient safety, quality/improvement issues, disease trends, and patient/learner satisfaction. These activities should enable residents to function as effective managers of safe, high-quality, acceptable, and user-friendly practices.

  • Bazemore A, Petterson S, Peterson LE, et al. More comprehensive care among family physicians is associated with lower costs and fewer hospitalizations. Ann Fam Med. 2015;13(3):206-213.
  • Grumbach K. To be or not to be comprehensive. Ann Fam Med. 2015;13(3):204-205.
  • O'Malley AS, Rich EC, Shang L, et al. New approaches to measuring the
    comprehensiveness of primary care physicians. Health Serv Res. 2019;54(2):356-366.
  • Ornstein SM, Nietert PJ, Jenkins RG, et al. The prevalence of chronic diseases and multimorbidity in primary care practice: a PPRNet report. J Am Board Fam Med. 2013;26(5):518-524.
  • Porter M, Malaty J, Michaudet C, et al. Outpatient referral rates in family medicine. American Journal of Accountable Care. 2018;6(1):25-28.
  • Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457-502.

Strengthen continuity of care in residency training

Practically speaking, continuity of care is associated with improved preventive and chronic care, higher patient and clinician satisfaction, and lower costs. It underlies the patient-physician relationship and is key to the educational value of teaching clinics.

The ways family physicians achieve continuity with their patients continue to evolve. Achieving continuity in residency is challenging for a variety of reasons, particularly if residents are scheduled for only the minimum required time in clinic. Programs of Excellence prioritize both the amount and predictability of scheduled time in the clinic.

While access and continuity have the potential to be in tension with one another, practices can build protocols that allow patients the flexibility to decide which takes precedence. Continuity of care for residency training and practice should not be reduced to transactional percentages and metrics.

The purpose of continuity is to allow time and space for a meaningful relationship to develop between the physician and patient.

To better understand these dynamics at the local level, it is imperative for residency practices to measure continuity and access and maintain an elevated level of both. At a minimum, residents should be assigned a continuity panel at the beginning of residency, and practices should ensure that all patients in the practice are empaneled.

The EHR must support resident primary care physician assignment and provide flexibility to update and modify patient panels for a variety of circumstances.

Residency programs should model continuity of care with the following qualities:

  • Regular/predictable schedules

  • Patient care sessions daily, with more frequent and longer sessions for senior residents

  • Partnership or team coverage of patients on a regular basis

  • Daily resident contact with the site by phone or through electronic means (e.g., the EHR) when the resident is not physically present at the family medicine practice (FMP) site

  • Ability to contact patients during and between office visits

  • Use of protocols to guide the right type of care at the right time through multiple
    alternatives visit types including, but not limited to, e-visits through a patient portal, phone and video encounters, group visits (also called shared medical appointments), and visits with non-clinician team members

A culture of learning rooted in evidence-based medicine should be developed, with an emphasis on point-of-service learning. The practice should develop a system for all patients to access their medical home and ensure continuity of care for both the patient and the clinician. Measures of continuity should be determined on a regular basis to define success and ways to improve continuity.

  • Bazemore A, Petterson S, Peterson LE, et al. Higher primary care physician continuity is associated with lower costs and hospitalizations. Ann Fam Med. 2018;16(6):492-497.
  • Liaw W, Jetty A, Petterson S, et al. Trends in the types of usual sources of care: a shift from people to places or nothing at all. Health Serv Res. 53(4):2346-2367.
  • McWhinney IR. Continuity of care in family practice. Part 2: implications of continuity. J Fam Pract. 1975;2(5):373-374.
  • Phillips RL, Dodoo MS, Green LA, et al. Usual source of care: an important source of variation in health care spending. Health Aff (Millwood). 2009;28(2):567-577.
  • Saultz JW, Albedaiwi W. Interpersonal continuity of care and patient satisfaction: a critical review. Ann Fam Med. 2004;2(5):445-451.
  • Walker J, Payne B, Clemans-Taylor BL, et al. Continuity of care in resident outpatient clinics: a scoping review of the literature. J Grad Med Educ. 2018;10(1):16-25.

Build coordinated, team-based primary care

Coordinated, team-based care is essential to improve the patient experience, deliver better health outcomes, and preserve physician well-being. Coordination within teams has the potential to optimize capacity in access and scope of services.

In residency teaching practices, care coordination inherently has additional complexities that include multiple “part-time” clinicians, competing priorities, and the transient nature of residency training. Increased transitions of care and handoffs raise the risk of medical errors, inconsistent care plans, and patients lost to follow-up.

Models that foster the ability to better coordinate team-based care may offer potential solutions to ongoing shortages of primary care clinicians and the increasing gap between supply and demand for primary care services.

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Family physicians should retain a leadership role in identifying and addressing issues that impact a patient’s comprehensive ability to thrive and be well.

The community context and patients’ social needs require team-based care to extend beyond the walls of the physical FMP. In a Program of Excellence, practice leadership will incorporate collaboration with public health and community-based organizations.

Training practices should screen for social determinants of health and help connect patients to available resources once needs are identified.

As behavioral health is accepted as an integral part of whole-person care, mental health services must also be integrated into primary care so that it can be truly coordinated and comprehensive.

Surrounding family physicians with the appropriate multidisciplinary team allows them to distribute responsibilities to ensure improved care for their patients, decrease the non-physician workload, and expand access by managing a larger patient panel.

  • Blumenthal KJ, Chien AT, Singer SJ. Relationship among team dynamics, care coordination and perception of safety culture in primary care. Fam Pract. 2018;35(6):718-723.
  • Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573-576.
  • Caines LC, Brockmeyer DM, Tess AV, et al. The revolving door of resident continuity practice: identifying gaps in transitions of care. J Gen Intern Med. 2011;26(9):995-998.
  • Christian E, Krall V, Hulkower S. Primary care behavioral health integration: promoting the quadruple aim. N C Med J. 2018;79(4):250-255.
  • Ghorob A, Bodenheimer T. Sharing the care to improve access to primary care. N Engl J Med. 2012;366(21):1955-1957.
  • O'Gurek DT, Henke C. A practical approach to screening for social determinants of health. Fam Pract Manag. 2018;25(3):7-12.
  • Rodriguez HP, Rogers WH, Marshall RE, et al. Multidisciplinary primary care teams: effects on the quality of clinician-patient interactions and organizational features of care. Med Care. 2007;45(1):19-27.
  • Vimalananda VG, Dvorin K, Fincke BG, et al. Patient, primary care provider, and specialist perspectives on specialty care coordination in an integrated health care system. J Ambul Care Manage. 2018;41(1):15-24.

Support sustainability and innovation in the family medicine practice

Value-based financial models should improve upon sustainability for high-functioning primary care practices. However, value-based care delivery principles must be demonstrated for primary care clinics and residency programs to be successful.

Until value-based measures are clearly established, productivity and financial planning remain important. Impact assessments of proposed changes to the business model should be thorough and transparent.

Members of the practice and residents should receive at least quarterly data, including metrics related to the Quadruple Aim. During the transition to value-based payments, members of the practice and residents should continue to receive reports analyzing the number of patients seen, diagnostic and demographic data, work relative value units (wRVUs) generated, gross billings, and collections. Residents should also receive feedback on their documentation and coding.

  • Arenson C, Brandt BF. The importance of interprofessional practice in family medicine residency education. Fam Med. 2021;53(7):548-555.
  • Bazemore A, Grunert T. Sailing the 7C’s: Starfield revisited as a foundation of family medicine residency redesign. Fam Med. 2021;53(7):506-515.
  • deGruy FV, McDaniel SH. Proposed requirements for behavioral health in family medicine residencies. Fam Med. 2021;53(7):516-520.
  • Harper DM. Family medicine researchers—Why? Who? How? When? Fam Med. 2021;53(7):647-649.
  • Kahn NB Jr. Redesigning family medicine training to meet the emerging health care needs of patients and communities: be the change we wish to see. Fam Med. 2021;53(7):499-505.
  • Lehmann C, Liao W. The patient voice: participation and engagement in family medicine practice and residency education. Fam Med. 2021;53(7):578- 579.
  • Neutze D, Hodge B, Steinbacher E, et al. The practice is the curriculum. Fam Med. 2021;53(7):567-574.
  • Wheat S. Community: the heart of family medicine. Fam Med. 2021;53(7):528-531.