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. Since 2015, the AETC Program has implemented 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 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.
- PCPCC Report (2015). The patient-centered medical homes impact on cost and quality: Review of evidence 2013-14.
- 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.
- Center for Quality Improvement and Innovation
- 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.
- 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.
- HRSA/HAB Center for Quality Improvement and Innovation
- AHRQ Resources for engaging primary care practices in quality improvement, AHRQ.
- 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.
- AHRQ Primary Care Practice Facilitation Curriculum
- 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
Active Resources: 13
Mental health and substance use disorders are highly prevalent among people with and at risk for HIV.Type: Clinical Reference ToolsPublish Date: 8/16/2021
To address the importance of oral health and reduce oral health disparities for people with HIV, HRSA HAB identified challenges, best practices, and strategies implemented by RWHAP recipients to inType: Clinical Reference ToolsPublish Date: 4/5/2021
This PrEP protocol is adapted from the US Public Health Service, Preexposure Prophylaxis for the Prevention of HIV IType: Clinical Reference ToolsPublish Date: 3/4/2020
This resource was developed by Providence Community Health Centers (PCHC) as part of a New England AETC practice transformation project. HRSA population health measures were added to the PCHCType: Clinical Reference ToolsPublish Date: 11/13/2019
This multi-module curriculum is designed for all health-care providers and covers various topics.
Type: Online and Self-Paced LearningPublish Date: 11/1/2017
The website is structured around a set of strategic practices that health departments can apply to more meaningfully and comprehensivType: Web LinksPublish Date: 7/18/2017Review Date: 5/6/2021
The Impact of Primary Care Practice Transformation on Cost, Quality, and Utilization reviews PCMH results from 45 peer-reviewed reports and additional government and state evaluations.Type: Articles, Reports, and ManualsPublish Date: 7/10/2017
At the end of this activity, you will be able to:Type: Online and Self-Paced LearningPublish Date: 5/19/2017
IHI’s QI Essentials Toolkit includes the tools and templates you need to launch and manage a successful improvement project.Type: Clinical Reference ToolsPublish Date: 5/19/2017
Although designed for use in ambulatory surgery centers, this toolkit has several tools customizable for applications in HIV care.Type: Clinical Reference ToolsPublish Date: 5/1/2017
Recent surveys to the NEJM Catalyst Insights Council revealed that executives, clinical leaders, and clinicians – who each come at health care delivery from a distinct vantage point – are aligned oType: Articles, Reports, and ManualsPublish Date: 2/22/2017
Developed by the AETC Mental Health Committee for the Integrating Mental Health and Substance Use Care into HIV Primary Care ToolkitType: Clinical Reference ToolsPublish Date: 6/2/2015Review Date: 5/17/2019
This guide aims to improve patient care. It gives practical advice on how to encourage healthcare professionals change their practice in line with the laType: Articles, Reports, and ManualsPublish Date: 12/1/2007Review Date: 5/14/2019
Archive Resources: 10
An Infographic for Providers on the Benefits of Coding for SDHType: Clinical Reference ToolsPublish Date: 5/9/2017
Researchers at IHI have been working to identify and test the “active ingredients” that make for continuous improvement and continuous quality control at the front line in health care.Type: Articles, Reports, and ManualsPublish Date: 1/2/2017Review Date: 5/19/2021
In support of U.S.Type: Articles, Reports, and ManualsPublish Date: 5/2/2016Review Date: 5/18/2021
Excerpt from the Executive Summary
As in previous editions, this year’s Annual Review of the Evidence provides a summary of PCMH cost and utilization results froType: Articles, Reports, and ManualsPublish Date: 2/1/2016Review Date: 5/17/2019
The Transforming Clinical Practice Initiative Support and Alignment Network contains information on the Transforming Clinical Practice Initiative and the Collaborative Care Model (CCM) which integrType: Web LinksPublish Date: 1/1/2016
This May 2011 report is from an expert panel supported by the:
Type: Articles, Reports, and ManualsPublish Date: 8/31/2015
- American Association of Colleges of Nursing
- American Association of Coll
Type: Articles, Reports, and ManualsPublish Date: 8/31/2015
Jan E. Patterson, MD, FACP, FIDSA, CPE
UTHSCSA & South Texas Veterans Health Care System
Martha Medrano, Veronica Young, Kathleen Stevens, John Herbold,Type: Articles, Reports, and ManualsPublish Date: 8/13/2015
Table of Contents
Chapter 1: Introduction
Chapter 2: What is PracType: Articles, Reports, and ManualsPublish Date: 7/29/2015
This report reviews a national study on the scheduling, waiting time, and access experiences of persons trying to get health care. Recommendations are provided in the way of best practices.Type: Articles, Reports, and ManualsPublish Date: 6/29/2015
Addressing the HIV Outbreak among People with HIV and the American Indian Community: MATEC Minnesota's HIV Practice Transformation Project Successes
The Native American Community Clinic (NACC) in Minneapolis has been highly successful in integrating HIV care into their Federally Qualified Health Center (FQHC). Minnesota has eleven sovereign American Indian (AI) nations1, and the Phillips neighborhood of Minneapolis (where NACC is...
Cross-posted from TargetHIV coverage of the 2018 National Ryan White Conference.
Regional AETCs across the United States are working to bring new clinicians into the HIV workforce through inter-professional education (IPE) programs. IPE trains learners in teams in clinical...
Moving beyond culture competency to cultural humility acknowledges patients’ authority over their own lived experience
Health care delivery often involves a one-size-fits-all approach. As clinicians, we treat a patient with a particular diagnosis similar to the last patient we saw with the same...
The AIDS epidemic raged around me like a wildfire in the late '80s and early '90s while I trained in medicine in San Francisco. During that storm, I began working with people with HIV. In 1995, ready to start a primary medical practice, I landed at a community clinic in Berkeley, California,...
I remember driving to Chicago on my first day as a Midwest AETC Practice Transformation (PT) Coach. I was filled with both excitement and apprehension to participate in a intensive training titled Building Blocks of High Performing Primary Care. While the concepts of PT were familiar to...