Practice Transformation

Practice transformation refers to a process of change in the organization and delivery of primary care to advance quality improvement, patient-centered care, and characteristics of high performing primary care. The AETC Program will implement projects to support and facilitate practice transformation in selected clinics in order to improve patient outcomes along the HIV care continuum by integrating principles of the patient-centered medical home model and integrated HIV care and behavioral health services. The practice transformation process involves goal-setting, leadership, practice facilitation, workflow changes, quality improvement and outcomes measurement, and adapting organizational tools and processes to support advances in models of team-based care.

•   Websites with Resources to Explore

  Websites of organizations that support practice transformation and advancement of the patient-centered medical home model of care have many resources to explore. Some of the organizations offer regular webinars on diverse topics and are continually adding new materials. Others provide a repository of materials and lessons learned from completed projects. In addition to specific resources listed under topics below, explore the following websites to identify other resources and tools.

  • Agency for Health Research and Quality (AHRQ) Patient Centered Medical Home Resource Center (AHRQ)

    Tools and resources address the 5 functions and attributes of the medical home model as defined by the AHRQ: comprehensive care, patient-centered care, coordinated care, accessible services, quality and safety. The site also has resources about implementing the PCMH, including a Primary Care Facilitation Curriculum.

  • Patient-Centered Primary Care Collaborative

    The PCPCC website includes resources grouped under 5 Stakeholder Centers: Advocacy and Public Policy, Care Delivery and Integration, Employers and Purchases, Outcomes and Evaluation, Patients Families and Consumers. It also provides an archive of webinars and videos.

  • Primary Care Development Corporation

    The PCDC website includes multiple resources on the patient-centered medical home, meaningful use and health information technology and other topics. It also provides an archive of webinar resources.

  • Medical Home Initiative for Safety Net Clinics

    This website provides an archive of resources and tools from the completed Medical Home Initiative for Safety Net Clinics.

  • Center for Excellence in Primary Care, University of California San Francisco, Department of Family and Community Medicine

    Offers resources, tools for practice transformation and training about health coaching, panel management, practice coaching, complex care management.

  • Improving Chronic Illness Care

    This was a national program of The Robert Wood Johnson Foundation dedicated to the idea that United States health could do better. It includes resources on the chronic care model, care coordination, practice change, patient-centered medical home, global work, evidence for better care, and a resource library.

  • Primary Care Team Guide. Improving Primary Care: A guide to better care through teamwork.

    This website site was produced by the staff of the MacColl Center for Health Care Innovation at Group Health Research Institute and includes Resources to Get Started, Build the Team and Do the Work.

  • Annals of Family Medicine

    The Annals of Family Medicine has published many articles on models of primary care, the patient-centered medical home and practice transformation. The searchable website offers full access to published articles.

  • Coach Medical Home

    This website offers online curricula and resources based on the Safety Net Medical Home Initiative Framework for supporting primary care clinics in practice transformation.

•   Getting Started

  • PCPCC Report (2015). The patient-centered medical homes impact on cost and quality: Review of evidence 2013-14.
  • Crossing the Quality Chasm: A New Health System for the 21st Century
  • How-to-guide for organizations interested in starting a practice facilitation program aimed at improving care.
  • Primary Care Team Guide. Improving Primary Care: A guide to better care through teamwork. GET STARTED. Find out how to get the most from this guide, includes a short webinar introduction to the website.
  • The Safety Net Medical Home Initiative Coaching Guides.
  • HRSA/HAB National Quality Center

•   Practice Readiness Assessment Tools

  • Patient-Centered Medical Home Assessment (PCMH-A)
  • Practice Transformation Tools, Center for Excellence in Primary Care University of California San Francisco, Department of Family and Community Medicine.
    • Building Blocks Assessment Tool
  • Joint Commission Primary Care Medical Home (PCMH) Self-Assessment Tool: Self -assessment tool that can be used to determine to what extent the PCMH requirements are being met.
  • NCQA 2014 Medical Home Assessment Tool: Tool to help providers and staff navigate the National Committee for Quality Assurance's Patient-Centered Medical Home 2014 recognition process. Helps guide practices through the NCQA medical home survey process.
  • Primary Care Development Corporation: Free PCMH 2014 readiness assessment tool to help primary care practices make informed decisions about moving forward with PCMH recognition. PCDC's tool helps guide practices through the NCQA medical home survey process.

•   Engaging Leadership

  • IHI: Engaging physicians in a shared quality agenda
  • Engaged Leadership: Strategies for guiding PCMH transformation
  • Seven leadership leverage points for organization-level improvement in health care
  • How Inclusive Leadership Can Help Your Practice Adapt to Change

•   Quality Improvement Tools

  • HRSA/HAB Center for Quality Improvement and Innovation
  • AHRQ Resources for engaging primary care practices in quality improvement, AHRQ.
    • Engaging Primary Care Practices in Quality Improvement. Strategies for Practice Facilitators. Quick Start Guide and Full manual.
  • Quality Improvement Strategy PT 1: Tools to Make and Measure Improvement
  • Quality Improvement Strategy PT 2: Optimizing Health Information Technology for Patient-Centered Medical Homes
  • The run chart: a simple analytical tool for learning from variation in healthcare processes
  • Fishbone/Ishikawa diagram: visualization tool for categorizing the potential causes of a problem in order to identify its root causes.
  • Plan-Do-Study-Act (PDSA) Worksheet
  • Scatter Diagram: Graphs pairs of numerical data to look for a relationship between them. Use this diagram to design a control system to ensure that gains from quality improvement efforts are maintained.

•   Practice Transformation Facilitator Training Programs

  • AHRQ Primary Care Practice Facilitation Curriculum
  • Millard Fillmore College
  • Center for Excellence in Primary Care
  • Practice Transformation Institute-Troy, Michigan
  • HealthTeamWorks' Workforce Development Training
  • National Committee for Quality Assurance (NCQA)
  • Joint Commission Accreditation and Primary Care Medical Home (PCMH)
  • Accreditation Association for Ambulatory Health Care, Inc.
  • URAC's Patient Centered Medical Home Program

•   Newsletters and Forums

  • Patient-Centered Primary Care Collaborative Newsletter
  • Primary Care Development Corporation Newsletter
  • Agency for Healthcare Research and Quality Electronic Newsletter
  • Agency for Healthcare Research and Quality Primary Care Practice Facilitation Forum