Action steps and roles

1. Convene a time-limited group of practice leaders.

Suggested team member(s) responsible: chief medical officer (or equivalent), office manager or QI coordinator.

Start with a small group of leaders from your practice (some of whom will be on the implementation team) who can help refine the “charge” or scope of work of the implementation team and both identify and engage the people/roles that will be required to implement the scope of work of the team.

2. Develop a preliminary scope of work or charge outlining the responsibilities of the implementation team.

Suggested team member(s) responsible: time-limited group of practice leaders.

This scope or charge includes but may not be limited to enabling, aligning, leveraging and supporting the planning and implementation of all foundational activities in this implementation guide so that the practice meets the foundational competencies for chronic conditions. This should include a tentative timeline, core activities, and key roles and responsibilities.

However, there may be further foundation-building work needed at your practice in order to succeed at the above key activities. The Population Health Management Capabilities Assessment Tool (PhmCAT) is a multidomain assessment that is used to understand current population health management capabilities of primary care practices. This self-administered tool can help your practice identify opportunities and priorities for improvement.

If your practice does not score highly in the domains of leadership and culture, the business case for population health management, technology and data infrastructure, or empanelment and access, consider implementing the activities listed in the four guides on Building the Foundation before or in parallel to working on key activities related to management of chronic conditions.

3. Identify leadership and key actors for the implementation team.

Suggested team member(s) responsible: time-limited group of practice leaders.

The multidisciplinary implementation team should include those empowered to make changes in workflows, policies and staff assignments. They should be respected influencers in the organization (early adopters), who can also guide the change management process. They should include those with expertise in partnering with patients with diabetes and hypertension management.

• Appoint a “champion” or lead person (e.g., chronic conditions care coordinator or diabetes care coordinator) to oversee the implementation and coordination of the team.
• Identify key staff who will be the core members of the implementation team. These people will likely include one or more panel managers, clinicians, nurses, administrators, data analysts, social workers, community health workers, and other community outreach staff, information technology (IT)/electronic health record (EHR)-related personnel, and human resources personnel.
• For the chronic conditions multidisciplinary team, it is important to include members of the clinical team, patient support team, outreach team, social support team and EHR/data team. This could include a core team and an expanded team. Potential members include:
  • Adult/family primary care clinicians (medical doctor, doctor of osteopathic medicine, advanced practice registered nurse, physician assistant).
  • Endocrinologist.
  • Cardiologist.
  • Registered dietician.
  • Certified diabetes educator.
  • Nurse.
  • Medical assistant (MA) or licensed vocational nurse (LVN).
  • Social worker.
  • Care coordinator.
  • Community health worker.
  • Pharmacist.
  • A member of the IT or EHR team (as part of the expanded team).
  • QI lead.
  • Billing manager or similar (as part of the expanded team).
  • A frontline staff member who interfaces with patients by phone and at check-in.
• Invite identified people to become part of the implementation team and ensure that they have appropriately designated time for participation.
• Teams should engage representation from IT to support the work of pulling data from the EHR and embedding updated data into tracking and evaluation.

4. Launch the implementation team and set it up for success.

Suggested team member(s) responsible: clinical coordinator or chief operating officer or chief medical officer.

This work includes:

• Ensuring that the team understands its charge or scope of work by developing a Multidisciplinary Implementation Team Charter Template, that outlines this work. Groups should work with each other to establish rapport and psychological safety as they develop team norms, which help teams to work together effectively.
• Defining roles and responsibilities, including the anticipated commitment (in hours) on a monthly basis.
• Establishing a meeting structure, file structure and communications structure to support effective, efficient work.
• Dedicating time and effort to forming, storming, norming and performing as a team. The Team Communication and Working Styles Template is one tool that team members can complete and share with other teammates to accelerate this process.
• Understanding baseline data related to outcomes of interest (e.g., hypertension control rates, hemoglobin A1c control rates), along with data related to known and perceived barriers to these outcomes.
• Prioritizing elements within the scope of work, informed by baseline data and identified population needs.

5. Develop a simple yet robust measurement strategy and learning system to guide your improvement efforts.

Suggested team member(s) responsible: implementation team.

A learning system enables a group of people to come together to share and learn about a particular topic, to build knowledge, and to speed up improved outcomes. A measurement strategy and learning system:

• Contains a balanced set of measures looking at outcomes, processes and possibly unintended secondary effects (e.g., increased cycle time and impact on team well-being).
• Incorporates the patient perspective and the perspective of staff (front desk and others), care team members, providers and management.
• Allows the team to determine if the process or system has improved, stayed the same or gotten worse.
• Helps guide improvement efforts and informs practice operations. See Appendix A: Sample Idealized System Diagram: Weaving Measurement and Learning Into Practice Operations for a sample system diagram of how your measurement strategy can be used to support practice operations.

Your practice should track the core and supplemental measures for hypertension control, comprehensive diabetes management and preventive ambulatory care visits. These can be considered outcome measures because there is ample evidence that improved care and management of chronic diseases will improve overall population health outcomes for effective chronic disease management.

In addition to the core and supplemental measures, practices should track process measures and balancing measures. Appendix C: Developing a Robust Measurement Strategy describes and defines the key milestones in the development of a robust measurement strategy, including definitions for each of these terms.

Suggested process measures:

• The percentage of patients 18 to 75 years of age with diabetes (type 1 and type 2) who receive a hemoglobin A1c test during the measurement year (NQF 0057).
• Percentage of patients ages 18 or older who are screened for high blood pressure and, if elevated or hypertensive, have a follow-up plan documented (CMS22v12).
• Percentage of adults who respond to a reminder to get scheduled for their visit.
• Percentage of adults who are due for a preventive/ambulatory visit that the practice reaches out to in order to schedule them if they are not already scheduled.
  Suggested balancing measures:
• One or more measures related to patient satisfaction.
• One or more measures related to staff satisfaction.

Practices can also look at other metrics to understand the progress of specific improvement initiatives over time. This may include:

• Progress on the Population Health Management Capabilities Assessment Tool (PhmCAT).
• Progress towards foundational competencies listed in this implementation guide. For example: “Yes or no: Did your practice achieve the foundational competency “Screen for Chronic Conditions?”
• Any other care gaps, clinical guidelines or measures your practice feels are important to prioritize.

Applying an equity lens

Your practice is likely achieving better outcomes with some patients than others. To understand these inequities, your practice should stratify your data based on race, ethnicity and language (REAL); sexual orientation and gender identity (SOGI); and other patient characteristics (e.g., social needs, etc.). See more in Key Activity 4: Use a Systematic Approach to Decrease Inequities within the Population of Focus. The ability to segment data in such a manner can lead to profound insights about structural challenges that drive some of the health outcomes. The Advancing Equity Through Data Quality and Reporting section of the PHMI Data Quality and Reporting Guide provides more guidance on this.

Putting it all together

We recommend that your practice record your measurement strategy in one place. This Measurement Strategy Tracker contains all the fields we believe are most useful; it can be customized to meet your practice’s needs.

6. Plan and hold regularly scheduled meetings of the implementation team.

Suggested team member(s) responsible: team lead or clinical coordinator or other individual tasked with coordinating the work of the team.

• Hold time on team members' calendars for standing meetings. Consider biweekly (twice monthly) meetings to start with. The frequency, duration and focus of these meetings may change as you consider additional populations or subpopulations and additional sites or locations, and as the nature of the work changes.
• Having a clinical perspective is an important aspect of this work. Consider models that minimize overall impact to patients’ ability to access care (i.e., having meetings before working hours or during lunch times; having providers attend crucial, rather than all, meetings; scheduling during providers’ administrative time).
• Develop a system to efficiently report on all workstreams and track follow-up items. The Action Plan Template is one tool that can be used to focus your team around the foundational competencies and define responsibility for actions steps to be taken for each project your team has prioritized to work on.

7. Make adjustments based on data from the team’s measurement strategy and feedback loops.

Suggested team member(s) responsible: multidisciplinary team.

• Review data and feedback at least monthly and adapt efforts as needed. Adaptation could include any or all of the following:
  • Amending the scope of work.
  • Modifying meetings or meeting structures.
  • Changing the team composition (adding or removing members).
  • Refining activities to better meet the needs of patients and staff, improve outcomes, or reduce inequities.
  • Modifying the measurement strategy and/or feedback loops to better understand what is (and is not) happening.
• On an annual basis, the team’s charter and core membership should be reviewed. As the goals of the implementation team are met, the team could disband, meet less frequently (e.g., twice per year) or fold this meeting into a similar standing meeting that occurs separately.

Evidence base for this activity

Pandhi N, Kraft S, Berkson S, Davis S, Kamnetz S, Koslov S, Trowbridge E, Caplan W. Developing primary care teams prepared to improve quality: a mixed-methods evaluation and lessons learned from implementing a microsystems approach. BMC Health Serv Res. 2018 Nov 9;18(1):847. doi: 10.1186/s12913-018-3650-4. PMID: 30413205; PMCID: PMC6230270.

Action steps and roles

1. Review the current, most up-to-date clinical guidelines and update appropriately.

Suggested team member(s) responsible: medical director (or equivalent) and quality improvement lead.
See the section titled Clinical Practice Guidelines earlier in this guide. Ensure your practice is using the latest guidelines.

In addition to those guidelines, you can review the following resources:

• ADA diabetes care recommendations (2023 standards).
• 2017 American College of Cardiology (ACC)/American Heart Association (AHA)/American Academy of Physician Assistants/Association of Black Cardiologists/American College of Preventive Medicine/American Geriatrics Society/American Pharmacists Association/American Society of Hypertension/American Society for Preventive Cardiology/National Medical Association/Preventive Cardiovascular Nurses Association Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults.

PHMI Clinical Practice Guidelines.

• Kaiser Permanente Adult Blood Pressure Clinical Practice Guidelines.
• Kaiser Permanente Type 2 Diabetes Screening and Treatment Guideline.

2. Develop standard methods of updating clinic staff on changes within key guidelines.

Suggested team member(s) responsible: medical director (or equivalent) and quality improvement lead.
These updates could be provided during a set meeting time, via email communication, via video update, etc.

3. Ensure access to evidence-based clinical decision support systems.

Suggested team member(s) responsible: administration and medical director (or equivalent).
Clinical decision support provides staff with information that is relevant to the care situation at appropriate times to enhance health and healthcare.^[5] This provides easy access to support such as clinical practice guidelines and medication alerts. These are sometimes integrated into the Electronic Health Record (EHR).

4. Regularly evaluate and support the infrastructure of patient care teams to ensure adequate redundancy and staffing.

Suggested team member(s) responsible: administration, medical director (or equivalent) and nursing director (or equivalent).

Part of developing the infrastructure for care teams to properly integrate clinical guidelines is providing adequate equipment for staff. This includes providing validated, automated monitors and adequate supplies of all blood pressure cuff sizes to each care team. Point-of-care A1c tests are another aspect of infrastructure that can be considered. Staff should also be trained upon hire, and annually thereafter, on proper blood pressure measurement procedures. This ensures that all staff are trained and available to utilize equipment. Staff should also be trained on other aspects of workflows, such as rooming, pre-visit planning (PVP), huddles, etc., in order to ensure that care does not suffer if a crucial staff member is unavailable on a certain day.

Additionally, practices should regularly evaluate clinic workflows and clinician panels to ensure that the number of staff that are allocated to each area is adequate. See the PHMI Empanelment Guide and Care Teams & Workforce Guide for more information.

5. Develop guidelines that reflect a spectrum of treatment needs.

Suggested team member(s) responsible: administration, medical director (or equivalent) and nursing director (or equivalent).

Guidelines should provide evidence-based recommendations for intensification of treatment, which emphasizes performance feedback. This can be for initiatives such as following up on lab results or utilizing guidelines for medication measures. Additionally, clinicians should be educated regarding how to best address common side effects and lab abnormalities.

Action steps and roles

1. Build the data infrastructure needed to accurately collect REAL, SOGI, social needs and other demographic data.

Suggested team member(s) responsible: data analyst.

• Race, ethnicity and language (REAL)
• Sexual orientation and gender identity (SOGI)

The PHMI Data Quality and Reporting Guide provides guidance and several resources for collecting this information. According to this guide, the initial step in addressing inequities is to collect high-quality data that fosters a holistic view of patient characteristics and needs. This entails incorporating REAL data, demographic data (age, SOGI, geography) and social needs data. By collecting and monitoring this information, healthcare practices can gain valuable insights into inequities in access, continuity and health outcomes. Steps 2 to 4 below provide more information on this process.

Collecting REAL information allows practices to identify and measure inequities in care while also ensuring that practices are able to interact successfully with patients. This is done by understanding patients’ unique culture and language preferences.^[9] KHAQuality.com has a toolbox that assists with REAL data collection.

The Uniform Data System Health Center Data Reporting Requirements (2023 Manual) provides detailed guidance on REAL and SOGI. Note: While UDS does not currently require that practices report on the specific primary language of each patient, practices should make an effort to identify and record each patient’s primary preferred language since UDS reporting still requires languages other than English to be reported.

Accurate data collection requires appropriate fields and options in the EHR and other employed technologies, as well as appropriate human workflows in collecting the data. Staff responsible for data collection should be continuously trained and assessed for best practices in data collection, including promotion of patient self-report.

In addition, practices should work to ensure that patients understand the importance and use of this information to help them feel comfortable with supporting its collection. High rates of “undetermined” or “declined” responses in these fields may be indicative of the need to train staff in how to ask these questions and to communicate the importance of the information and how it will be used to improve the healthcare the patient receives. An example of how this was incorporated into a practice was Lyon-Martin Community Health Services partnering with its EHR provider in order to build trust with disclosing this type of data.

Collecting this data is important, especially to obtain a complete picture of health for patients who identify as transgender. There are certain risks and condition indicators that are gender specific, which impact how clinicians provide care to a patient. The World Professional Association for Transgender Health has provided further guidance regarding standards of care related to gender diversity.

2. Use the practice’s EHR and/or population health management tool to understand inequitable health outcomes at your practice by stratifying your data.

Suggested team member(s) responsible: data analyst.

This includes reviewing your care gap report/care registry and being able to stratify all of the following:

• Core measures for the population of focus.
• Supplemental measures for the population of focus.
• Process measures for the population of focus.

Stratify this data by:

• REAL.
• SOGI.
• Other factors that can help identify subpopulations in need of focused intervention to reduce an equity gap (e.g., immigrants, people experiencing homelessness, etc.).

This is not a one-time event, but rather a continuous process (see step 13 below). It should be done in tandem with step 3 below.

Each practice should define the frequency of review and use of its registry to stratify data. In early use, the stratified data will support the identification of areas of inequity and allow for interventions to be prioritized.

See also Key Activity 3: Use Care Gap Reports or Registries to Identify All Patients Eligible and Due for Care.

3. Screen patients for social needs.

Suggested team member(s) responsible: care team.

Key Activity 17: Use Social Needs Screening to Inform Patient Treatment Plans provides guidance on screening patients for health-related social needs and how the information can begin to be used to inform patient treatment plans, including referral to community-based services. This is not a one-time event, but rather a continuous process. It should be done in tandem with step 2 above.

4. Analyze the stratified data from steps 2 and 3 to identify patterns in inequitable outcomes within the population of focus.

Suggested team member(s) responsible: data analyst, QI leads and care team.

Analyze the stratified data from steps two and three to identify patterns in inequitable outcomes.

This includes:

• Utilizing tools to examine, visualize and understand disparities across different populations or subpopulations.
  • Data over time (using run charts).
• Exploring trends, patterns and significant differences to understand which demographic groups will require a focused effort to close equity gaps.

Update your practice’s measurement strategy so your practice’s improvement efforts remain centered around advancing equitable outcomes. Some examples include creating specific, measurable, achievable, relevant, time-bound, inclusive and equitable (SMARTIE) goals and updating your process and outcome measures so you can understand differences by REAL or SOGI indicators. See Appendix C: Developing a Robust Measurement Strategy for more.

This is not a one-time event but rather a continuous process (see step 13 below). Periodic review of stratified data allows for recognition of gap closures and emergence of new disparities.

5. Conduct a root cause analysis for each subpopulation that the practice does not yet have equitable outcomes for.

Suggested team member(s) responsible: multidisciplinary team.

Select root cause analysis approaches that work best for the equity gap you are closing include:

• Engagement with and gathering of information from patients affected by the health outcome in your root cause analysis (see step 6).
• Brainstorming.
• Systems thinking (understanding how interconnected social, economic, cultural and healthcare access factors may be impacting the health outcome).
• Tools that rank root causes by their impact and the feasibility of addressing them (e.g., a prioritization matrix and/or an impact effort matrix).
• Visual mapping of root causes and effects (e.g., fishbone diagram).
• Focused investigations into selected root causes to gather qualitative data through interviews, surveys or focus groups with the subpopulation of focus.

Present the findings to a broader group of stakeholders to validate the identified root causes and gain additional insights. Incorporate the stakeholders’ feedback and refine the analysis, as needed.

6. Partner with patients to develop insights that will help you develop successful strategies.

Suggested team member(s) responsible: care team and people with lived experience (patients who are members of the population[s] of focus).

Using one or more human-centered design methods, such as focus groups, 7 - Stories, Journey mapping, etc. (see links to these methods below), work with members of each population of focus to better understand:

• Their assets, needs and preferences.
• Cultural beliefs, including traditional healing practices.
• Beliefs and level of trust in healthcare generally and in the topic of focus specifically (e.g., cancer screening, immunizations, behavioral health, etc.).
• Barriers to accessing care.
• Barriers to remaining engaged in care.
• Trusted sources of information or communication mechanisms for this population.
• Their ideas for improving health outcomes.

The patients you partner with for this and other steps in this key activity may be part of a formal or informal patient group and/or identified and engaged specifically for this equity work.

7. Identify key activities that address or partially address the root causes of the identified equity gaps.

Suggested team member(s) responsible: care team and people with lived experience.

Based upon the insights your practice has developed for a population of focus and your root cause analysis, determine which of the key activities in this implementation guide could address or partially address the equity gap. This could also include making physical adjustments to the environment in order to make the practice more welcoming or culturally responsive.

Most of the key activities in this guide either explicitly address an equity challenge or can be adapted to better address an equity challenge. Examples of key activities that can be adapted to reduce identified equity gaps include (but are not limited to):

• Key Activity 20: Strengthen Community Partnerships.
• Key Activity 11: Screen for Chronic Conditions.
• Key Activity 8: Proactively Reach Out to Patients Due for Care.
• Key Activity 17: Use Social Needs Screening to Inform Patient Treatment Plans, such as providing a referral for one of the CalAIM Community Supports.
• Key Activity 18: Coordinate Care.
• Key Activity 22: Continue to Develop Referral Relationships and Pathways.
• Key Activity 23: Strengthen a Culture of Equity.

8. Develop new strategies/ideas to address the identified equity gaps.

Suggested team member(s) responsible: care team and people with lived experience.

If one or more of your root causes cannot be addressed fully through key activities in this guide, use one or more human-centered design methods (see resources below) to develop ideas to improve health outcomes and reduce inequities among people with chronic conditions.

Developing these ideas is best done with representatives who are diagnosed with a chronic condition (as they have expertise and experience that may be missing from the practice’s care team). Compensating these patients and community members for time spent on improvement activities is a best practice. During this brainstorm, you are developing ideas without immediate judgment of the ideas in an effort to generate dozens of potentially viable strategies.

Selected resources on human-centered design and co-design

• Center for Care Innovations (CCI) Human Centered Design Curriculum via CCI Academy.
• IDEO’s The Field Guide to Human-Centered Design.
• IDEO’s Design Kit: Methods.

9. Determine which strategies to test first.

Suggested team member(s) responsible: care team and people with lived experience.

Steps 7 and 8 above help your practice identify existing key activities and generate new ideas.

There are many ways to prioritize ideas. The Institute for Healthcare Improvement often recommends a priority matrix.

If you have organized your key activities and new ideas into themes or categories, you may choose to work on one category or select one to two ideas per category to work on.

The number of key activities and/or new ideas that you prioritize for testing first should be based on the team’s bandwidth to engage in testing. Therefore, it is critical to determine the bandwidth for the team(s) that will be doing the testing so that you can determine how many ideas to test first.

10. Use quality improvement (QI) methods to begin testing your prioritized key activities and new ideas.

Suggested team member(s) responsible: care team and people with lived experience.

Nearly all the key activities and all of your new ideas will require some degree of adaptation to use them within your practice and to be culturally relevant and appropriate to your patients.

Use plan-do-study-act (PDSA) cycles, generally starting as small as feasible (think in ones — e.g., one clinician, one hour, one patient, etc.) and becoming larger as your degree of confidence in the intervention grows.

Whenever testing a key activity or new idea, we recommend that the practice:

• Use PDSA cycles to test your ideas and bring them to scale. See more information on PDSAs below in the Appendix C: Developing A Robust Measurement Strategy.
• Generally, start with smaller-scale tests (e.g., test with one patient, for one afternoon, in a mailing to 10 patients, etc.). Use the chart titled How Big Should My Test Be? in the Implementation Tips section below to help you decide what test size is most appropriate.

Develop or refine your learning and measurement system for the ideas you are testing. A simple yet robust learning and measurement system will help you understand improvements, unintended secondary effects and how implementation is going.

By working out the inevitable challenges in the idea you are testing using a smaller-scale PDSA cycle, ultimately, the improvement activity will work better for patients and be less frustrating to the care team. Testing and refining also can eliminate inefficient workarounds that occur when a new process or approach is imposed onto an existing system or workflow.

Select resources on Quality Improvement (QI)

Institute for Healthcare Improvement’s Quality Improvement Essentials Toolkit, which includes:

• Cause and effect diagrams.
• Driver diagrams.
• Failure modes and effects analysis.
• Flowcharts.
• Histograms.
• Pareto charts.
• PDSA worksheet.
• Project planning form.
• Run charts.
• Scatter diagram.

IHI’s Videos on the Model for Improvement (Part one and Part two).

• Rapid Experiments to Improve Healthcare Delivery.
• CCI’s ABC's of QI via CCI Academy.

11. Implement (bring to full scale and sustain) those practices that have proven effective.

Suggested team member(s) responsible: care team.

Once an idea has been well tested and shown to be effective on a small scale, it is time for your practice to “hardwire” the idea, approach or practice into your daily work. Consider using the MOCHA implementation planning worksheet to think through:

• Measurement.
• Ownership.
• Communication (including training).
• Hardwiring the practice.
• Assessment of workload.

Sometimes implementation may require that you update your protocol and/or policies and procedures for the populations of focus.

12. Once you have tested, refined and scaled up the initially prioritized ideas, begin testing other ideas.

Suggested team member(s) responsible: care team and people with lived experience.

This might include going back to ideas that were elicited previously but were not initially prioritized for implementation. You might also move through the testing steps above to generate and prioritize new ideas or adapt ideas to better serve additional subpopulations of focus.

13. Establish formal and informal feedback loops with patients and the care team.

Suggested team member(s) responsible: care team.

To help ensure that your practice’s ideas are meeting the needs of patients (and their families), helping to reduce identified equity gaps, and are feasible/sustainable for your practices, it is important to have both formal and informal feedback loops.

For patients (and their families), feedback loops might include:

• Sharing ideas with the population of focus to gather feedback and ensure accuracy before testing.
• Getting feedback from patients directly after testing new ideas with them (and incorporating their feedback into your next test).
• Patient satisfaction surveys (or similar).
• Follow-up calls with a subset of patients to understand what works well and what could be improved.
• Patient focus groups.
• Having the practice’s patient advisory board or similar provide feedback.
• For the care team, feedback loops might include:
• Existing or new staff satisfaction/feedback mechanisms.
• Regularly scheduled meetings/calls to get staff feedback on processes, methods and tools.

14. Continually analyze your data to determine if your efforts are closing equity gaps.

Suggested team member(s) responsible: care team.

This includes regular (at least monthly) review of the stratified measures for all of the following:

• Core measures for the population of focus.
• Supplemental measures for the population of focus.
• Process measures for the population of focus.
• Social needs data.
• Any additional measures collected as part of your testing and refinement effort.

Share the data with patients to both show your work to decrease known equity gaps and to solicit ideas for closing them.

Action steps and roles

1. Identify subpopulations among your patients who may benefit from outreach.

Suggested team member(s) responsible: panel manager or data analyst with care teams.

Some methods for identifying subpopulations to reach out to may include:

• Start with frequent no-show patients. Seek to understand their reasoning behind the no-shows, which may be related to social health-related needs or health literacy issues.
• Ask your care teams to identify patients they consider high-risk patients who have been lost to care.
• This may also include reaching out to patients who have not been seen in the last 12 months.
• Conduct outreach to patients whose last blood pressure was not controlled but who did not have a follow-up.
• Use care gap reports to identify patients who are behind on screening or who have missed a follow-up visit.
• Review all patients who are due for a follow-up review of their care plan or who have not had an updated blood pressure or glucose laboratory test; prioritize those patients for outreach.

See Key Activity 3: Use Care Gap Reports or Registries to Identify All Patients Eligible and Due for Care for more information.

2. Establish the outreach model for your practice.

Suggested team member(s) responsible: practice leadership.

One commonly used outreach model is to hire dedicated staff as population health specialists who are responsible for using care gap reports to conduct proactive outreach and to schedule follow-ups. See more about this in the PHMI Care Teams and Workforce Guide Resource 2: Care Team Duties and Recommended Education and Licensure resource.

Different teams may adjust this role to fit their needs. This model ensures that each care team includes staff with knowledge of the local environment.

Train all outreach staff in cultural humility, motivational interviewing skills and the use of trauma-informed care. See more in the resource: Trauma-Informed Population Health Management.

3. Supplement your reminder system for contacting various subpopulations.

Suggested team member(s) responsible: population health specialist, with guidance from implementation team and IT staff.

Reminders should be sent to all persons with an upcoming scheduled appointment. The clinic scheduling system will likely have a function for generating automated reminders with an option for patients to cancel or reschedule if they cannot keep the appointment. Reminders should also be sent to all patients who appear to have gaps in care and missed appointments. See more about updating your care gaps reports to enable setting up automated reminders in Key Activity 3: Use Care Gap Reports or Registries to Identify All Patients Eligible and Due for Care. The reminders could include a request to bring medications and any home-monitoring readings, such as home glucose and blood pressure readings. These are valuable resources for clinicians as they allow the clinicians to complete an accurate medication reconciliation and review the readings during the patient’s appointment.

Automated reminder systems support efficiency and reliability. However, more intensive reminders where the patient receives a personalized telephone call from their care team may help patients who are at higher risks of nonattendance or being lost to care.^[10]

FIGURE 13: PROACTIVE OUTREACH AND ENGAGEMENT

See the PHMI Care Teams and Workforce Guide Resource 6: Workflow Examples for more information.

Utilize multiple pathways to reach and engage patients. For example, a Swiss clinic used sequential appointment reminders consisting first of a phone call and second a text if patients did not answer the phone after three attempts. If the patient had no phone number listed, they received a postal reminder two days prior to their appointment. The reminder system significantly reduced the rate of missed appointments and allowed the clinic to reallocate 28% of the canceled appointments.^[11]

Reminders should accommodate language requirements, as well as stated patient communication preferences (text, email, mail or phone). Reminders that include standard information (appointment date, time, clinic location), as well as information about what to expect and additional clinical information, may be more effective.^[12]

4. Use “touches” that provide alternatives to the traditional office visit.

Suggested team member(s) responsible: extended care team, including community health workers and population health specialist, with guidance from implementation team.

Assess what types of interactions/care can be provided outside of a typical office setting. Collaborate with patients as part of their care planning to understand their preferences for communication and care team interactions. Examples of alternative interactions include, but are not limited to:

• Nursing staff visits (virtual).
• Pharmacy visits.
• Digital communication through emails, texts and patient portals.
• Newsletters focused on a specific condition.
• Social media that includes discussion groups related to the management of conditions of focus.
• Home visits for high-risk, underserved, or mobility-challenged patients.
• Other technological solutions, such as apps focused on patient conditions that provide a vehicle for ongoing engagement.

For patients with diabetes, group visits often can result in peer support systems that contribute to health literacy and assist with addressing health-related social needs. See Key Activity 19: Provide Group Visits for Chronic Care Management for more information.

Foster patient’s ability to self-monitor their diabetes and/or hypertension at home: For patients with hypertension and/or diabetes, empowering patients to self-measure their blood pressure can influence their health literacy and lifestyle choices. See Key Activity 24: Develop System to Provide Remote Patient Monitoring for more information.

5. Establish a process for engaging patients assigned to your practice by their managed care team who have not yet been seen by the practice.

Suggested team member(s) responsible: multidisciplinary implementation team.

Depending on your agreement with the health plans, it is important for practices to make a proactive plan to build capacity to accommodate assigned-but-not-yet-seen health plan patients in the clinic. Practices should develop strategies for outreach and engagement with these populations in order to shift them from not yet seen to fully engaged in primary care.

6. Continuously reassess outreach approaches with a goal of improvement.

Suggested team member(s) responsible: population health specialist.

Test your outreach approaches and measure their effectiveness. Outreach can be measured by reviewing data from missed appointments, numbers lost to follow-up, etc.

Survey patients to obtain retrospective and prospective feedback on outreach efforts.

Regularly update outreach strategies based on community feedback and changing demographics.

Evidence base for This activity

Biola H, Deyo J, Hayes T, Small L, Chaplin J, Pak-Harvey E, et al. Reaching the Hard-to-Reach: Outcomes of the Severe Hypertension Outreach Intervention. American Journal of Preventive Medicine [Internet]. 2020 Nov 1;59(5):725–32. Available from: https://www.ajpmonline.org/article/S0749-3797(20)30291-9/fulltextDenberg TD, Myers BA, Eckel RH, McDermott MT, W. Perry Dickinson, Lin CT. A patient outreach program between visits improves diabetes care: a pilot study. International Journal for Quality in Health Care. 2009 Apr 1;21(2):130–6.

Action steps and roles

The steps below outline the actions and steps required to create standing orders. These steps are adapted from the University of California, San Francisco’s Center for Excellence in Primary Care.^[14]

1. Review and understand the latest clinical guidelines for the required standing order and your practice’s already established protocols.

Suggested team member(s) responsible: Quality improvement lead and ​panel manager or data analyst or medical director (or equivalent).

For guidelines from the United States Preventive Services Task Force (USPSTF), the USPSTF site should be reviewed at least annually and/or upon notification of changes to ensure that the latest recommendations are being used by the practice.

The University of California, San Francisco’s Center for Excellence in Primary Care provides guidance on developing standing orders along with examples of standing orders for several clinical conditions.

Regardless of the specific guidelines being used by the practice, the care team should monitor the website containing these guidelines at least annually and/or upon notification of changes to ensure that the latest recommendations are being used by the practice.

Resources

• USPSTF’s Prediabetes and Type 2 Diabetes Screening Guidelines.
• ADA’s Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Care in Diabetes—2023.

2. Translate the appropriate clinical guidelines into a standing order.

Suggested team member(s) responsible: panel manager or data analyst.

The standing order will follow the relevant clinical guidelines (and be updated whenever clinical guidelines are updated).

They should allow registered nurses (RNs), Licensed Vocational Nurses (LVNs), and/or Medical Assistants (MAs) with proper training to initiate the agreed upon standing order process if the patient does not have any clinical history that may require a clinician to address the concern themselves. Actions that may be initiated during a standing order include an order, a referral or a clinician notification of the need for a screening/test.

Some examples of standing orders to review are from the Great Plains Quality Innovation Network, University of California, San Francisco, San Francisco Health Plan and Idaho Health West. Chapa-De Indian Health also developed a diabetes protocol for medication refills, which provides examples of what could be checked prior to refilling a medication as part of a standing order.

Redwood Community Health Coalition (now Aliados Health) provided this policy and procedure template for their patient health centers. It includes standing orders for treatment intensification by registered nurses. The American Academy of Family Physicians developed a plan to assist practices in utilizing standing orders to help teams work to their highest level.

In addition to the written standing order, the practice should develop a standard workflow (or similar tool) outlining how the standing order is to be implemented and how it fits into the practice’s existing workflow (with or without changes to the practice’s existing workflow).

3. Obtain approval for standing orders from clinical leadership.

Suggested team member(s) responsible: panel manager or data analyst and medical director (or equivalent).

For the standing order to be valid and in effect, it must:

• Be approved by clinical leadership at the practice.
• Be signed and dated by a designated valid signatory (i.e., medical director or other physician).
• Include the effective date for the standing order.

Practices should consider including an expiration date to help ensure that the standing order is reviewed and updated regularly. If possible, a notification should be put in place to ensure that the order is reviewed regularly. As the clinical guidelines change or other components of the standing order are updated, the standing order should be signed and dated again by the appropriate party with an effective date for the revision.

4. Train practice staff on how to use standing orders.

Suggested team member(s) responsible: medical director or equivalent.

It is critical that practice staff, both those directly named in the standing order and other members of the care team, receive training on the use of the standing order. Training should include a thorough review of the written standing order, the associated workflow and any additional materials related to the workflow, such as patient education or instructional materials. Documents, such as a checklist, may be utilized to provide resources for clinic staff. This standing orders checklist for diabetic patient visits guides a team-based care approach and ensures that patients get the care they need at each visit.

Training should be provided on each standing order at least annually. Updated training should be provided before the effective date on any revisions. Training should also be part of the orientation for all new members of the practice care team. Based on feedback from the staff, the standing order can be refined to make the instructions clearer (e.g., several staff members who are confused by a specific instruction during training indicates that the instruction needs to be revised).

5. Regularly review the standing order to ensure it is effective.

Suggested team member(s) responsible: clinical director or equivalent (or their designee).

It is likely that one or more aspects of the standing order will not work as planned. For example, the practice’s workflow may not fully support the standing order, the wording may be confusing or the standing order’s protocol may not be followed correctly (i.e., staff are using workarounds). The practice should routinely check for these and other common challenges and revise/update the standing order as needed to ensure that it works for the practice and meets all applicable regulations and guidelines.

Evidence base for This activity

• Alberti LR, Garcia DPC, Coelho DL, Lima DCAD, Petroianu A. How to improve colon cancer screening rates. World Journal of Gastrointestinal Oncology [Internet]. 2015 [cited 2019 Dec 10];7(12):484. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4678395/Ishida K, Weiss E, Kee SA, Yingling CT. Increasing colorectal cancer screening orders using unlicensed assistive personnel. BMJ Open Quality. 2019 Jun;8(2):e000545.
• Percefull J, Butler J. Improving mammography through effective screening, brief intervention, and referral to treatment at a rural health center. Journal of the American Association of Nurse Practitioners. 2020 Jan 16; Publish Ahead of Print.

Action steps and roles

1. Assess the current state of the PVP process across your practice.

Suggested team member(s) responsible: implementation team or QI team.

Understand how the process currently works for all visit types (e.g., scheduled, same day, virtual) in light of your practice’s performance on core and supplemental measures.

Compile existing paperwork and process documentation into one place and talk to MAs and other members of the care team to understand their questions and challenges around the PVP process.

Consider making current-state process maps that communicate the major steps in the PVP process and acknowledge pain points or challenges in the process. Pain points are places where the process is not working well for patients, staff or specific subpopulations or demographic groups for whom your data analysis has revealed equity gaps. In addition, pay attention to places where staff are creating workarounds to the process. The presence of workarounds indicates that the process might need further clarification or refinement to support the care team to reliably implement it.

Your team may find it helpful to compile process maps both for the high-level PVP as detailed in Figure 14 and for more detailed documentation for specific clinical workflows.

FIGURE 14: EXAMPLE OF A HIGH-LEVEL PVP WORKFLOW

See the PHMI Care Teams and Workforce Guide Resource 6: Workflow Examples for more information.

2. Identify where to update the PVP process to more consistently and reliably address care gaps.

Suggested team member(s) responsible: implementation team or QI team – may include the data manager to assist with identifying patients through EHRs.

Examine where you can further incorporate or streamline your practice’s clinical protocols and standing orders into PVP, including via the PVP checklist, daily huddles and other key clinical workflows.

This may include the following discussion points:

• Who will initiate the discussion with the patient based on the needs (e.g., primary language) and preferences of the patient. It may be beneficial to have communications coaching or training for staff on how to ask or address difficult questions or conversations.
• How and when they will plan to have the discussion during the visit.
• How they will be prepared to address any barriers.
• What educational materials will be available for use that are relevant to the patient.

Examples and considerations for updating the PVP process are included below.

Clinical guidelines and care gaps: Consider which preventive and maintenance services could be addressed more reliably using PVP, including those in your EHR’s care gap module. The Pre-Visit Planning: Leveraging the Team to Identify and Address Gaps in Care resource provides a more complete list of preventive services for adults and children. Figure 15 provides an example of how your EHR might be able to support flagging any patient overdue for common maintenance services (A1c, LDL, nephropathy, eye exams, and foot exams).

FIGURE 15: PVP REPORT DETAILING OVERDUE PREVENTIVE AND MAINTENANCE SERVICES

PVP checklist: A generic PVP checklist to be completed by the MA or LVN at least one to three days before the appointment is provided in Figure 16. Most EHRs will have a health maintenance module that identifies what preventive care is due, but a printed or digital checklist provides a starting point for ensuring key steps are not missed.

FIGURE 16: PVP PLANNING CHECKLIST

FIGURE 17: EXAMPLE CHART SCRUB PROCESS FOR OPEN ORDERS

Daily huddles: Design or redesign the team’s daily huddle so the care team can review prioritized action items for the list of patients scheduled to come and any further follow-up for patients seen in the previous days. Work to incorporate it as part of the regular clinic schedule. For more information, see the PHMI Care Teams and Workforce Guide Resource 4: Daily Huddles Overview and Process.

The Center for Excellence in Primary Care resource on Healthy Huddles includes tools, a video and examples of how pre-visit planning (PVP) flows into the daily huddle process, including a healthy huddle warm-up, which can help MAs prepare for huddles.

Patients requiring special considerations: Ensure that the PVP includes a process to flag for the care team:

• Patients requiring special attention, such as those with complex needs or recent hospitalizations.
• Patients who need extended time or additional services during their visit (e.g., translation services, mobility assistance, screenings).

Specific consideration for patients with diabetes: The patient should be contacted one to four days prior to their appointment to ask them to bring in their glucometer and/or readings so that the clinician can review them. Additional steps may be required to prepare for a diabetes management appointment, such as reviewing if the patient has an adequate amount of diabetes management supplies (such as glucose meters, lancets, glucose test strips, etc.) and downloading/uploading the glucometer data if a patient is part of an RPM program. See Key Activity 24: Develop System to Provide Remote Monitoring for more information.

Detailed clinical workflows: Clinical workflows should be updated to describe at which step in PVP or the patient visit a care team member will address a specific gap in care with the patient.

Planning for care after the visit: Effective PVP includes scheduling pre-visit labs and other diagnostics at the end of the current visit, as well as coordinating care and referrals for services not available at the practice. Confirm the patient understands the purpose of any follow-up care. See Key Activity 18: Coordinate Care for more information.

The American Medical Association has an online guide for implementing PVP, which includes forms, templates and other resources.

3. Test planned changes to the PVP workflows and support care teams in implementing the workflow.

Suggested team member(s) responsible: implementation team or QI team.

Test and refine important changes to the PVP process with one or two care teams before considering rolling out the change more broadly at the practice.

Implementing the change includes updating documentation and creating a staff training schedule or training refresher for staff to sustain workflow changes. For example, train MAs every six months on the PVP. If they have difficulty, have them retake training with a different highly effective MA and monitor closely until competency in the task is reached.​ Infrastructure should be evaluated to ensure that there is adequate training and staff time to effectively complete this process.

Customizing the EHR: For further streamlining of the process, practices can customize their EHR template to align with PVP workflows. Be sure to account for potential costs associated with the creation of new templates, staff training and IT.

An example of this is Golden Valley Health Centers, which outlined workflows for their staff in relation to medication results based upon patient blood pressure results taken while in the clinic.

4. Establish a process to review and update PVP workflow.

Suggested team member(s) responsible: care team with quality improvement manager.

Identify staff responsible for reviewing and updating the PVP process at least annually to incorporate the latest clinical guidelines and check for any workarounds that have developed.

Action steps and roles

1. Streamline medication regime to ensure that the patient has the most effective treatment with the least amount of medication possible.

Suggested team member(s) responsible: clinician, pharmacist and patient.

Fixed-dose combination medications should be considered to achieve more effective hypertension management.^[17] Fixed-dose combination medications help to improve patient adherence, condition control and time to control. Many fixed-dose combination medications are covered by Medi-Cal (on formulary). This may also include employing use of interventions such as bubble packaging, medication delivery and others in order to reduce barriers to care.

2. Determine, in consultation with the patient, which healthy lifestyle changes are acceptable to them that they feel they can reasonably implement.

Suggested team member(s) responsible: clinician, patient and behavioral health consultant (if available).

Examples may include, but are not limited to:

• Increasing exercise.
• Switching to healthier food options (e.g., from white rice to brown rice, from cereal to oatmeal made with rolled oats, etc.).
• Incorporating more fruits and vegetables into the patient’s regular diet.
• Switching to fruits that have lower levels of natural sugar (e.g., switching from oranges to berries).

3. Consult, or refer the patient to, a behavioral health clinician who can assist with change management.

Suggested team member(s) responsible: clinician, patient and behavioral health consultant (if available).

The Shasta Community Health Center Quality Improvement Storyboard provides an example of integrating behavioral healthcare into diabetes care.

4. Refer the patient to other education or intervention options, as appropriate, for further assistance, such as case management, diabetes education or medically tailored meals.

Suggested team member(s) responsible: clinician, patient, and care coordination staff (or equivalent).

Evidence base for this activity

Petrie JR, Guzik TJ, Touyz RM. Diabetes, Hypertension, and Cardiovascular Disease: Clinical Insights and Vascular Mechanisms. The Canadian journal of cardiology. 2018 May;34(5):575–84.

Action steps and roles

1. Determine an agreed upon method and frequency with the patient for monitoring their blood pressure and/or glucose.

Suggested team member(s) responsible: medical staff and patient.

This may include, but is not limited to, RPM, journaling, etc. The method and frequency of monitoring should be evaluated regularly with the patient during their appointments. See Key Activity 24: Develop System to Provide Remote Monitoring for more information.

2. Work with the patient to ensure that they know how to properly utilize their blood pressure cuff and/or glucometer.

Suggested team member(s) responsible: medical staff and patient.

If possible, ask the patient to bring in their home blood pressure cuff to calibrate it with the clinic’s sphygmomanometer. One-on-one instruction during a nurse visit is a great opportunity to teach proper use. Training on proper blood pressure measurement technique and/or blood glucose measurement while in the clinic helps the patient to feel confidence while also correcting any improper techniques being utilized.

An example of this is Livingston Community Health, which utilized education to help patients feel adequately equipped to monitor their blood pressure at home.

3. Assist the patient to develop a network of support to help self-manage their chronic condition.

Suggested team member(s) responsible: medical staff, patient and caregiver.

A caregiver, family member or group (e.g., diabetes education or walking group, etc.) Groups are particularly beneficial due to their ability to generate relationships around a shared goal.

4. Assist the patient with understanding certain threshold diagnostics that they should be mindful of, which may warrant medical intervention (e.g., too high blood pressure, glucose value, etc.).

Suggested team member(s) responsible: medical staff.

Patients should be assisted with understanding when to reach out to their clinician with concerns and how to access care after hours for significantly abnormal diagnostics.

Example workflow

La Clinica de la Raza outlined in this case study how they implemented processes for patient self-monitoring of blood pressure.

Open Door Family Medical Centers chose to implement a blood pressure cuff loaner program in order to support a blood pressure patient self-monitoring program.

Action steps and roles

The action steps and roles outlined below provide a framework for assessing current state of care coordination, developing a strategy, implementing care coordination, and monitoring and learning as you progress.

1. Establish a “call to action” for care coordination.

Suggested team member(s) responsible: medical lead or care coordination staff or QI staff.

To achieve effective care coordination, your practice needs to see itself as a “hub” or “center” for coordination of patient care.

• While all clinicians within a patient’s support network need to collaborate, your practice should view itself as accountable for care coordination for empaneled patients and patients who have been assigned to your practice by their MCP.
• Identify a care coordination team that will be responsible for leading the evaluation, assessment and implementation of care coordination activities.
• Share with the care coordination team why care coordination is important.
• Some areas to address:
  • Discuss what care coordination is.
  • Discuss why care coordination benefits staff and patients.
  • Review proposed framework (assess, develop strategy, implement, monitor) to develop the care coordination activity.
  • Identify and share some initial projects that are directed at enhancing care coordination.
  • Invite and engage staff and patients to provide input on how they think care coordination can be enhanced.
  • Discuss how best to incorporate feedback from patients.

Use feedback from this activity and incorporate it into an assessment.

2. Assess your practice’s current state of care coordination activities.

Suggested team member(s) responsible: panel manager and QI lead.

Begin by asking and answering the following questions:

• What does the practice hope to achieve by implementing interventions to change the care coordination process?
• Which patient needs are the responsibility of the practice to provide (care coordination within the practice)?
• Which patient needs will need to be addressed through external referral and collaboration (care coordination with entities outside the practice)?

What resources are needed to improve the current state (data; input from care team members; input from care partners such as hospitals, specialty, behavioral health, social needs)?

Gather stakeholder input.

• Conduct interviews or surveys with patients and community members to understand their perspectives on current care coordination processes, challenges and areas for improvement.
• Conduct interviews with your care team to understand their perspectives on current care coordination processes, challenges and areas for improvement.

Analyze existing systems and processes.

• Review existing care coordination protocols, technologies and resources utilized by health centers.
• Explore how technology is currently being used to support care coordination. Then explore how technology could be harnessed to streamline care coordination, improve data sharing and/or enhance communication among clinicians.
• Review existing formal and informal linkage agreements.
• Conduct an analysis to determine patient needs not yet fully addressed by existing agreements.
• Assess data on patient outcomes, patient satisfaction and any existing QI initiatives.
• The following resources can help your practice assess its current state:
  • Population Health Management Capabilities Assessment Tool (PhmCAT): sections on population-based care, social health and behavioral health.
  • Care Coordination Maturity Assessment: This resource addresses multiple domains that may be impacted as care coordination activities are undertaken.

3. Develop and implement a care coordination improvement strategy.

Suggested team member(s) responsible: panel manager and QI lead.

Develop your high-level care coordination improvement strategy.

• The high-level strategy is based on the results and insights from your Care Coordination Maturity Assessment and your practice’s capacity (bandwidth).
• Establish clear objectives.
• Define specific, measurable, achievable, relevant, time-bound, inclusive and equitable (SMARTIE) goals for enhancing care coordination.
• Ensure that these goals align with the overall mission and values of your practice.
• Prioritize areas for improvement: Identify a limited set of key focus areas based on the assessment findings and your practice’s bandwidth, such as communication protocols, technology integration, staff training or patient engagement strategies.

Identify resources and infrastructure.

• As part of the implementation of the strategy, identify the resources and infrastructure needed to support care coordination at your practice.

We have included in Figure 19 below some considerations, by resource, as you develop your care coordination implementation plan (some of the resources may not apply to your practice).

FIGURE 19: CONSIDERATIONS FOR IDENTIFYING CARE COORDINATION (CC) RESOURCES

Develop staffing for care coordination.

Determine who at your practice will be involved in care coordination. The PHMI Care Teams and Workforce Guide Resource 1: Core and Expanded Care Team Functions, Team Members and Roles provides an overview on care coordination using a care coordinator or referral manager.

• Based on the population of focus and the intervention, develop staffing requirements and any job description changes to embed care coordination into your practice.
• The responsibilities of a person/people fulfilling care coordination roles should include, at a minimum:
  • Manage the referral process.
  • Assist patients with transitions, such as those to and from hospitals and other institutions.
  • Help patients resolve logistical, financial and/or other barriers to a successful referral.
  • Link patients with community resources.
  • Follow up with patients within a few days of an emergency room visit, hospital discharge or discharge from a treatment facility.
  • Ensure the safe transfer of patient data.
  • Track progress (referral milestones).
  • Assist patients who are having difficulties.
  • Schedule follow-up and specialty appointments for/with patients
• Formalize the referral coordinator role through a job description or position description. Sample referral coordinator position description.
• Provide regular training and support to care coordinator/referral coordinator or similar.

Develop or refine your policies and procedures for care coordination. At a minimum, this should include all of the following:

• Identifying patients who are eligible for care coordination.
• Defining the activities that are associated with care coordination (outreach, engagement, assessment, desired outcome).
• Managing the referral process.
• Ensuring the safe transfer of patient data.
• Tracking progress – closed loop referral.
• Identifying patients who would benefit from higher levels of care coordination, such as care management interventions like ECM (see Key Activity 21: Provide Care Management.)

Develop or refine your referral protocols.

Develop clear guidelines for when and how to make clinical referrals.

• Include criteria for urgent versus nonurgent referrals.

For each clinician your practice will be referring to:

• Identify the information, format and process the clinician requires to receive a referral.
• Share the information you will need back from the clinician (when the referral has been successfully made and/or once the service or support has been provided) to ensure continuity of care and nonduplication of services.
• Formalizing this through a written agreement or compact is a good way to ensure expectations on both sides of a referral are understood.

In working with community agencies or organizations that provide social support, the specific information that can and should be shared will depend on the service. It is important to have a mutual understanding about that information, using a written agreement where possible. At minimum, if the referral did not include a warm handoff, there should be an expectation that the practice hears back from the organization to let them know whether the patient followed up on the referral. See: Sample primary care checklist suggestions for assessing referral process.

Address connectivity. For any clinicians that you are exchanging patient data with, your practice should develop formal agreements and processes. Below are some considerations to facilitate information sharing among clinicians involved in an individual’s care:

• Integrate documentation platforms where possible and standardize how documentation is included in patient records.
• Ensure that behavioral health records are integrated into the overall EHR system to the extent permitted by law.
• Enable clinicians to access comprehensive patient information.
• Identify and assess participation in health information exchanges and/or social health information exchange systems, where feasible, to facilitate seamless sharing of patient information. These exist in some communities and will develop over time. This explainer series from the California Health Care Foundation describes the new statewide health information exchange coming into effect in 2024.
• Understand when patient consent is required to ensure compliance with privacy regulations, such as the Health Insurance Portability and Accountability Act. Include consent processes in the referral protocols.
• Set expectations about the information that should be shared and develop processes for facilitating that exchange. As data that is used in a clinical setting will likely be different than information that is shared by community agencies or social support networks, it is imperative to have clear parameters around what types of information can be exchanged between your practice and your partners.

Provide care coordination to patients.

In accordance with your care coordination policies and procedures and referral protocols, provide care coordination to patients who need it.

Embed care coordination into your practice’s daily workflow, including PVP. See Key Activity 10: Develop or Refine and Implement a Pre-Visit Planning Process.

• Sample care coordination task plan and weekly schedule.

Provide referrals to care management (See: Key Activity 21: Provide Care Management) such as ECM for patients who require more intensive support.

Discuss each referral with the patient to ensure the patient understands the reason for the referral.

Below is an example of a care coordination QI strategy.

FIGURE 20: EXAMPLE OF A CARE COORDINATION QUALITY IMPROVEMENT STRATEGY

The following resources can help your practice develop your care coordination improvement strategy:

• AHRQ care coordination web page.
• HEDIS measure – Transitions of Care (TRC).
• HEDIS measure – Follow-Up After Emergency Department Visit for People With High-Risk Multiple Chronic Conditions (FMC).

 4. Monitor continuous QI of care coordination

Suggested team member(s) responsible: QI lead.

Develop both formal and informal mechanisms to obtain feedback from clinicians, staff and patients on the effectiveness of your practice’s care coordination efforts and to identify areas for improvement.

Establish key performance indicators related to care coordination. Consider using AHRQ’s Care Coordination Quality Measures for Primary Care (CCQM-PC). Your performance indicators will vary based upon your improvement strategy and the needs of patients, but they may include metrics such as:

• Number of assigned patients engaged in care.
• Number of individuals with hypertension whose blood pressure is controlled.
• Percentage of closed loop referrals by referral entity. Monitor and analyze metrics to gauge the effectiveness of your internal systems and how well each referral partner is promoting coordination and collaboration.

Continue to build relationships with clinicians and community support agencies that are available to provide services to patients.

Consider developing and using a care coordination variance report. Here is a sample patient care coordination variance report.

Action steps and roles

1. Determine your group visit condition.

Suggested team member(s) responsible: clinical leadership.

Determine which condition you want to be the focus of your group visit. It is best to have group visits involving people with similar conditions who can share their own experiences and best practices in how they are adapting to their chronic condition.

2. Plan for group visits.

Suggested team member(s) responsible: LVN or MA.

Plan your group visit with a timed agenda outlining what will happen during the group visit (e.g., the educational component, nutrition counseling, when the clinician will see patients individually, any testing required during the visit, etc.). The Serve the People Community Health Center created a toolkit that provides guidance for planning and resourcing diabetes group medical visits, as well as flowsheets with roles and responsibilities outlined.

Pull charts three to five days before the group visit. As agreed upon by the team, perform chart review to identify specific patient needs to be accommodated and to identify gaps in care. Confirm whether you will have extended members of the care team participate, and recruit and prepare them for their roles (e.g., pharmacist, nutritionist, social worker, etc.). Staff should also prepare materials required for the visit (i.e., labels, education materials, etc.)

Remind the primary care clinician about the upcoming group visit. Ensure the room housing the group visit is ready and set up with all materials needed for the group visits. Community Medical Centers developed handouts for their group medical visits that address A1c, blood pressure, healthy eating and goal setting.

3. Determine how to bill for group visits.

Suggested team member(s) responsible: administration and billing staff.

Complete billing information as needed. Group visits should be billed as individual encounters as long as patients are seen one-on-one by the billing clinician during that visit. The level of complexity of the visit should include all services provided in this interdisciplinary shared medical appointment.

Billing is a common challenge for group visits. Keep in mind that during a group visit, the clinician sees every patient hands-on; therefore, this should be documented as a medical office visit and should follow traditional documentation for an individual visit. It is important to note that the physician's contact with the patient is longer than most routine office visits.

Since many other activities are happening during the group visit, you can add the appropriate modifiers to enable you to code at the correct level of intensity. For UDS purposes, the visit can be counted as an individual encounter as long as it meets the traditional criteria (each patient is seen one-on-one and the clinician is using individual clinical decision-making). See the UDS countable visits guide for more information.

4. Recruit patients for your pilot.

Suggested team member(s) responsible: clinicians and care team members.

Identify candidates and register them for a group visit after determining their level of interest. They should be identified based upon set criteria (i.e., current treatment adherence, care gap needs, treatment complexity, etc.).

5. Plan the visit with a clear understanding of the roles.

Suggested team member(s) responsible: Nursing Staff/Medical Providers

Circulate in the room during break, performing vital signs and identifying patients who need individual attention.

Provide a brief educational module and lead a discussion. An example would be for the physician/advanced practice professional to provide a five-minute brief education on what diabetes is and why complications arise. This might include visuals to help patients process the information. This would be followed up with a question-and-answer period where all patients benefit from questions from others.

During break, review individual needs and make one-on-one individual appointments for after the visit.

6. Evaluate and scale group visits.

Suggested team member(s) responsible: care team members.

A natural progression of group visits is to start with a single condition (such as diabetes) and an early adopter champion and then progressively scale your group visit model across your organization to be available for all eligible patients with that condition. Starting with a smaller group allows for challenges to be worked out before a larger rollout. This is not an insignificant challenge for health centers as it requires constant refreshing of the curriculum and updating information based on the latest evidence base.

A future activity is to expand your group visit model to other conditions, using what you have learned from your early pilots and scaling.

An advanced model for group visits incorporates your patients into the design and execution of the group visits. An example might be to include a patient with expertise in exercise and wellness as a future speaker for a module in a group visit.

Examples

In this quick video from a Canadian practice holding group visits for maternal health, the patients are empowered to do their own vitals. In this approach, an alternative clinician conducts the educational modules.

This alternative workflow from the University of Virginia focuses on women with cardiovascular disease.

The Group Visits Improve Diabetes Self-Management case study describes the implementation of diabetic group visits and the lessons learned at the East Valley Community Health Center.

Evidence base for this activity

• Beck A., Scott J., Williams P. Robertson B., Jackson D., Gade G., Cowan P. A randomized trial of group outpatient visits for chronically ill elderly HMO members: The cooperative healthcare clinic. Journal of the American Geriatric Society 1997: 45;543-549.
• Masley S., Solokoff J., Hawes C. Planning for group visits with high-risk patients. Family Practice Management 2000; 7:33-38.
• McKenzie M., Scott J. “Cooperative healthcare clinics deliver primary care in a group setting.” Guide to Managed Care Strategies, Burns J & Northrup LM, Eds. New York: Faulkner and Gray, 1998.Noffsinger EB, Scott JC. Understanding today’s group visit models. Group Practice Journal 2000:48(2):46-8, 50, 52-4, 56-8.
• Sadur CN, Moline N., Costa M., Michalik D., Mendlowitz D., Roller S., Watson R., Swain B.E., Selby J.V., Javorski W.C. Diabetes management in a health maintenance organization. Efficacy of care management using cluster visits. Diabetes Care. 1999 Dec; 22(12):2011-7.
• Scott J., Robertson B. Kaiser Colorado’s cooperative healthcare clinic: A group approach to patient care. Managed Care Quarterly 1996:4(3);41-45.
• Scott J.C., Gade G., McKenzie M., Venohr I. Cooperative healthcare clinics: A group approach to individual care. Geriatrics 1998:53(5);68-81.
• Terry K. Should doctors see patients in group sessions? Medical Economics January 13, 1997;74-95.
• Thompson E. The power of group visits. Modern Healthcare June 5, 2000.
• Beck A., Scott J., Williams P. Robertson B., Jackson D., Gade G., Cowan P. A randomized trial of group outpatient visits for chronically ill elderly HMO members: The cooperative healthcare clinic. Journal of the American Geriatric Society 1997: 45;543-549.

Action steps and roles

1. Start by understanding the resources and partnerships available through Medi-Cal.

Suggested team member(s) responsible: clinic operations and leadership staff who will liaise with community partners.

Resources include supports that are available to all Medi-Cal patients (such as transportation to medical appointments) as well Medi-Cal Community Supports for eligible individuals with higher levels of social needs. The following is a list of social support resources that are available to Medi-Cal patients when eligibility criteria are met:

• Transportation to medical and other Medi-Cal-covered appointments.
• In-home supportive services – personal home care assistance for those who qualify.
• Community-based adult services – day programs outside the home for individuals who need assistance with activities of daily living.

For individuals with the highest needs, the14 Medi-Cal Community Supports are:

• Housing transition navigation services.
• Housing deposits.
• Housing tenancy and sustaining services.
• Short-term posthospitalization housing.
• Recuperative care (medical respite).
• Day habilitation programs.
• Caregiver respite services.
• Nursing facility transition/diversion to assisted living facilities.
• Community transition services/nursing facility transition to a home.
• Personal care and homemaker services.
• Environmental accessibility adaptations (home modifications).
• Medically supportive food/meals/medically tailored meals.
• Sobering centers.
• Asthma remediation.

Contact the provider services department of your Medi-Cal Managed Care Plan to learn more about the providers of these services and specific providers in your area. With a list of contracted community-based organizations, your practice can start to build relationships and support ongoing social needs for your patients.

For an overview of Community Supports in the state, DHCS has provided information about the current state of Enhanced Care Management and Community Supports in the Community Supports Year 1 Summary and the Enhanced Care Management Year 1 Summary.

2. Complete an environmental scan to understand who your patients identify as trusted messengers and resources in their community.

Suggested team member(s) responsible: health center leadership, community health workers and social work staff.

This can be completed by interviewing patients and families and by confirming existing partner relationships. This can be completed with the assistance of community health workers. After that, a stakeholder map and community profile of key current and prospective partners can be developed.

Practices should also partner with hospitals, community behavioral health centers, public health agencies and other key stakeholders to refine your community needs assessments.

3. Convene partners as a work group to develop strategies and interventions to address health-related social needs.

Suggested team member(s) responsible: health center leadership.

In some cases, your practice may serve as a convener, bringing partners together for collaboration to avoid relying on individual relationships with external organizations. Be clear on your “asks and offers” to ensure the relationship will be mutually beneficial.

Develop a shared aim statement with your partners as to why this work is important and your vision of what you hope to achieve. Following the aim statement, formalize your structure and system of collaboration and accountability to ensure progress. This may take the form of ongoing pacing of meetings on a regular basis rather than relying on transactional relationships. To ensure proper understanding of expectations, roles and commitments, memorandums of understanding should be developed.

4. Collaborate with your partners to develop a shared set of strategies on a community approach to address health-related social needs.

Suggested team member(s) responsible: health center leadership.

The practice should benchmark and collate approaches to identify potential interventions for addressing health-related social needs. CalAIM resources should be leveraged as part of your intervention plans.

A driver diagram should be developed to guide your efforts and to set priorities.

5. Collaborate with partners to co-design and execute interventions and approaches to address health-related social needs.

Suggested team member(s) responsible: health center leadership.

Use workflow mapping tools, swim lane diagrams and checklists that clarify roles and plan initiatives. This allows the practice to develop clear action plans that clarify leaders of intervention strategies, timetables, and measures of progress and success.

Going deeper in strengthening partnerships: Addressing community needs requires sustainable and effective partnerships over time. A future activity includes your organization working with other community partners in an ongoing forum to address community needs. This often involves the health center as a backbone organization supporting a local collaboration governance structure for shared prioritization and action planning.

On the horizon in strengthening partnerships: A mature partnership system in a health center includes assessing the effectiveness of the partnerships and finding ways to continuously ensure alignment so that partnership remains a positive force for all participants. When possible, making adjustments that strengthen the partnerships can be explored (such as improving data sharing, pooling resources to increase leverage in the community, etc.).

Action steps and roles

1. Identify types of referral partners that your practice needs and gaps in resource availability.

• Some examples to consider: high-volume specialties such as ophthalmology, podiatry, dermatology, social services clinicians, substance use clinicians.
• In areas where you have gaps in referral clinicians, telehealth services may be an option. For further information on telehealth services – including e-consult and synchronous, asynchronous and e-visits – contact your MCP and/or refer to the Telehealth Reimbursement Guide for California (Pages 14 to 16). Referral processes and tracking are also important to establish for telehealth as well as in-person services.
• Note that there is a shortage of behavioral health clinicians in many parts of California. As you continue to expand your network of off-site behavioral health clinicians to meet pressing behavioral health needs, also consider behavioral health integration strategies, including expanding your practice’s capacity for providing integrated behavioral health services. See the PHMI People with Behavioral Health Conditions Guide for more about deepening and expanding integrated care.
• Work with the care teams for patients with diabetes and hypertension to identify gaps in referral resources that could enhance implementation of evidence-based care.
• Use social health screening results that have been disaggregated by REAL and SOGI alongside patient/family feedback to identify unmet needs for which resource relationships have not been established.

2. Assess what tools would be beneficial for the core elements of your referral process.

Examples include: (see resources below)

• Referral request form:
  • Determine what information is required for the clinician who is receiving the referral. Information may include the requested service; timing (urgent vs. standard); minimum necessary information, such as patient contact information and applicable demographics; and appropriate clinical and social support questions.
• Referral tracking spreadsheet or software:
  • Information in a tracking system can include date of referral, appointment status and whether follow-up is needed. Reach out to your Medi-Cal MCPs as you are developing referral tracking processes. The MCPs are required to show that Medi-Cal patients are being connected to the services that they are eligible for and referred to; this includes preventive services, specialty services and social services. The MCP may be a good resource for tools, such as those needed for tracking and reporting.
• Referral workflow diagram:
  • A visual representation or workflow diagram can support staff in the referral process. The Institute for Healthcare Improvement’s Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era provides a visual nine-step closed loop referral process for specialty referrals as well as suggestions for improving the process.

3. Assess what tools would be beneficial in enhancing and tracking your referral process.

• Referral guidelines:
  • For social services, positive responses to screening questions/tools may be the prompt for referral. Other types of referrals may be optimized by having documented referral guidelines, such as information needed by a specialty clinician in order to best answer a referral question.
• Communication templates:
  • For high-volume or frequent referral types, a standardized template for communication between the clinic and referral staff can help ensure that essential information is conveyed efficiently. Examples may include referral letters, progress notes and post-visit summaries of plan of care.
• Patient education materials (develop in conjunction with referral network):
  • Educational materials and resources for patients that explain the referral process and what to expect can enhance patient understanding and support referral completion. In addition, consider training MAs as well as any dedicated care coordination staff in evidence-based communication techniques, such as teach-back or motivational interviewing to leverage team-based care in supporting the patient to follow through with the referral after the visit.

4. Develop approaches to fill resource gaps.

Suggested team member(s) responsible: care team.

• Outreach to your Managed Care Plan (MCP) to understand what resources are available. MCPs are required to have online clinician directories that include specialists, which can be a resource used by a clinic to help find contracted specialists near the patient's home. In addition to comprehensive networks of over a dozen core specialty clinicians and information on behavioral health and substance use resources, many MCPs are building links to access community-based resources in addition to the 14 Medi-Cal Community Supports through referral platforms that act as a hub to coordinate social needs for patients.
• Identify external clinicians and community resources that can serve as partners in care, and use the established referral process to fill gaps in care they can address.
• Meet/schedule time with high-volume clinicians, including community-based organizations, to develop a mutual understanding of the goals of referrals and opportunities for development of a shared process (e.g., referral form).
• The American Academy of Pediatrics offers a sample tool to develop a resource list.

5. Regularly review and update the referral processes and network.

Suggested team member(s) responsible: clinic leadership.

• As new patient needs are identified, use that opportunity to identify potential resources and expand the referral network. If practices have trouble accessing a contracted specialist for their patient because of overly long wait times or because the specialist may not be accepting new patients, the MCP is required to approve an out-of-network referral to a specialist who is more available.
• On a periodic basis, review referral tracking reports to identify referral resources that are used most frequently, and use that information to reinforce the relationships and provide feedback on value.
• Review referral tracking reports to identify resources for which loop closure is lacking or from whom required information is not being received on a regular basis. Outreach to these organizations to reinforce expectations, or if necessary, identify a replacement resource for the network.
• For going deeper in tracking QI metrics, practices can develop metrics to assess the effectiveness of the referral network. This might include tracking referral completion rates, patient satisfaction and time from referral to specialist appointment.

Action steps and roles

1. Determine which types of capabilities are most important for RPM devices.

Suggested team member(s) responsible: quality improvement staff, EHR specialist (or equivalent), medical director and practice administration.

When purchasing RPM devices, determine which types (if any) are compatible with your chosen EHR. This should allow information to be transcribed directly into the EHR. It is also an option to contract with an RPM company, which can assist with developing infrastructure.

2. Determine clinical protocols for determining if an RPM device is appropriate for the patients’ care.

Suggested team member(s) responsible: medical director (or equivalent) and quality improvement staff.
These protocols should be based upon clinical guidelines for diabetes and hypertension.

3. Determine how to properly code for RPM and train clinicians on how to execute proper billing practices.

Suggested team member(s) responsible: billing office and practice administration.

4. Train clinical staff and/or designate a staff member for each clinician to assist patients with setting up and linking RPM devices to the EHR.

Suggested team member(s) responsible: Quality Improvement staff and EHR specialist (or equivalent).

5. Provide the patient with instructions for how often to use the device to obtain the respective diagnostic and how to properly utilize the RPM device.

Suggested team member(s) responsible: medical staff.

Assist the patient with linking their RPM with the EHR to ensure a transfer of information.

The American Medical Association maintains a list of clinically validated blood pressure monitoring devices (see the article to access the list).

6. Assist the patient with understanding certain threshold diagnostics that they should be mindful of, which may warrant medical intervention.

Related Resource

AHA’s patient resource for monitoring blood pressure at home.

View Resource

Suggested team member(s) responsible: medical staff.
If practices identify that a patient has a diagnostic that warrants medical intervention, they should reach out to the patient to engage them in appropriate care. Such diagnostics may include, but are not limited to, critically high blood pressures, critically high glucose readings, etc.

7. Designate staff to troubleshoot and assist with RPM-related challenges.

Suggested team member(s) responsible: Quality Improvement staff, EHR specialist (or equivalent) and practice administration.
This can include staff who monitor outputs from remote monitoring to ensure threshold triggers are acted upon (such as high glucose or blood pressure).

8. Considerations for high-risk patients.

Suggested team member(s) responsible: core care team members, care coordinators and navigators, and community health workers.

An alternative that may be available for high-risk patients is to have a community care team, including a nurse and community health worker, that is able to go to the patient’s home on a regular basis and can assist with diagnostics.
An example is Neighborhood Healthcare, which did what many healthcare organizations did during the COVID-19 pandemic – it quickly pivoted to telemedicine. However, some of its ailing low-income patients lacked the technology or digital skills needed for virtual care, so Neighborhood Healthcare decided to bring it to them. This case study outlines how Neighborhood Healthcare accomplished this.

Example workflow

CCI’s RPM clinic workflow journey map: This is a collection of workflows from community health clinics in California that expanded their use of RPM for blood pressure measurements.

Evidence base for this activity

• Tucker KL, Sheppard JP, Stevens R, Bosworth HB, Bove A, Bray EP, et al. Self-monitoring of blood pressure in hypertension: A systematic review and individual patient data meta-analysis. Rahimi K, editor. PLOS Medicine. 2017 Sep 19;14(9):e1002389.

APPENDIX A:

Sample Idealized System Diagram

WEAVING YOUR MEASUREMENT STRATEGY AND LEARNING SYSTEM INTO PRACTICE OPERATIONS

The below graphic provides an example to visualize the flow of information between a practice’s measurement strategy and actions at the practice and care team levels, including how to use the information for continual learning and improvement.

APPENDIX B:

Theory of Change

The key activities in this guide align with the PHMI theory of change for how practices can increase utilization of comprehensive care protocols for controlling high blood pressure and comprehensive diabetes care.

• Effective implementation of chronic care management protocols.
• Patients living with diabetes and hypertension have a care plan that effectively addresses their medical, behavioral and social health needs.
• Practices have needed resources and support.

FIGURE 22: PHMI PEOPLE WITH CHRONIC CONDITIONS DRIVER DIAGRAM.

APPENDIX C:

C: Developing a Robust Measurement Strategy

FIGURE 23: DEVELOPING YOUR MEASUREMENT STRATEGY MILESTONES

The visual below illustrates the key milestones in the development of a robust measurement strategy.

FIGURE 24: DEFINITION AND EXAMPLES FOR MEASUREMENT STRATEGY MILESTONES

Figure 24 provides guidance on each of these milestones as you work to put in place a robust yet practical measurement strategy.

APPENDIX D:

Other Sources Reviewed in the Writing of This Guide