Patient-Centered Primary Care Program – Provider Toolkit
At the heart of medical home transformation is a core set of elements which position a primary care practice to maximize its return on effort investment—returns characterized by making progress in sustainable change that favorably impacts patient experience, quality outcomes, and total cost of care. Some of these “Core Elements” point to engaged practice leadership, embedded use of QI methodology including incorporation of data use to drive change, and shifting the practice delivery paradigm to a team-based model where all team members have a role in providing efficient, patient-centered care that is appropriate to that team member’s level of training.
You may recognize that our program milestones closely mirror the program expectations described in Appendix A of your Program Description and contract. The milestones are founded on industry best practices drawn largely from the data we now have as a result of the many medical home pilots that have been implemented across the nation—many of which we have directly participated in or supported. While the milestones help to frame program expectations, there are associated indicators which we’ve defined that will help you to both anticipate how your practice will evolve as a result of participating in our program as well as see how much progress you are making in terms of reaching the milestone goals set before you.
Our “Provider Toolkit” is offered to you as just one of the many resources that accompany our patient-centered care program to support your achievement of success as you journey through the changes asked for by this program. It is framed by our ten program milestones and contains reference tools, best practice examples, resource toolkits created by organizations expert in practice transformation focus areas, relevant papers, and example templates. The Provider Toolkit also includes important Anthem-specific documents which your practice will find helpful as your team begins to actively participate in our patient-centered care program.
Provider Toolkit Topics
Resources, including toolkits and papers, to support establishment of internal infrastructure to coordinate care.
Resources, including Anthem materials, to assist you in establishing processes and workflows to utilize reports and MMH+ for population health management and high risk patient stratification.
Care planning templates and resources to support establishing a reasonable process in your practice for shared care planning that incorporates self-management support, goal setting, and action planning.
Population health registry guides and other materials to help you set-up and maintain a registry and use its functionality for patient outreach, closing gaps in care and managing prevention and chronic disease needs of patients.
Materials to assist your practice maximize EHR or other available HIT for evidence-based care delivery and relevant Clinical Decision Support.
Methods to engage your patients and support your practice in transitioning to a culture of patient- centered care.
Resources to establish expanded office hours, cross-coverage arrangements after hours, and online communication and visits for your patients within the patient-centered care model.
Resources to support the setting up of external processes and infrastructure to sustain coordination of care outside of the medical home.
Program metrics, report how-tos, and options for helping patients to decrease ineffective and unnecessary use of clinical resources are all examples of supports available to help you achieve improved clinical and utilization outcomes.
The American College of Physician’s Medical Home Builder® and other related resources provide your practice with additional PCMH content to help you achieve Level III NCQA recognition as a medical home, a strongly encouraged, but optional milestone.