For GCACH, the Patient Centered Medical Home model of care is the foundation for practice transformation, but it’s not all that our Practice Transformation team delivers to our provider organizations. Based upon the following initiatives and evidence-based care models, our team realized GCACH had designed our own model of care and thus named our new toolkit, “The Greater Columbia Cares Model." This model incorporates best practices from the Institute for Healthcare Improvement (IHI), the Comprehensive Primary Care Initiative, Six Building Blocks, the Safety Net Medical Home, the Agency for Healthcare Research and Quality (AHRQ), and Robert Wood Johnson Foundation’s Culture of Health.
One initiative, the Institute for Healthcare Improvement (IHI) quotes a proverb that I think relates directly to our vision for our partnering providers implementation plan.
An Irish proverb says, “When you come upon a wall, throw your hat over it, and then go get your hat.” At IHI, the spirit of this one little saying has inspired many big outcomes. The Institute for Healthcare Improvement takes a unique approach to working with health systems, countries, and other organizations on improving quality, safety, and value in health care. This approach is called the science of improvement. The science of improvement is an applied science that emphasizes innovation, rapid-cycle testing in the field, and spread in order to generate learning about what changes, in which contexts, produce improvements. It is characterized by the combination of expert subject knowledge with improvement methods and tools. It is multidisciplinary — drawing on clinical science, systems theory, psychology, statistics, and other fields.
Comprehensive Primary Care Initiative (CPCI)
The Comprehensive Primary Care Initiative supports the provision of a core set of five “Comprehensive” primary care functions. (1) Risk-stratified Care Management; (2) Access and Continuity; (3) Planned Care for Chronic Conditions and Preventive Care; (4) Patient and Caregiver Engagement; (5) Coordination of Care. CPCI was a five-year advanced primary care medical home model launched in 14 regions. In January 2017. CPC+ was launched including all seven original CPC regions. CPC+ integrates many lessons learned from CPC, including insights on practice readiness, the progression of care delivery redesign, actionable performance-based incentives, necessary health information technology, and claims data sharing with practices.
Evidence Based Practices Six Building Blocks
Many practices are looking for help in managing their patients using chronic opioid therapy. The Practice Transformation team is trained to deliver a structured, systems-based approach for improving management of patients on chronic opioid therapy called the Six Building Blocks. The blocks include: demonstrating leadership support and consensus, revising and implementing policies, patient agreements, and workflows, proactively tracking and monitoring patient care, implementing planned, patient-centered visits, developing resources to care for complex patients, and measuring implementation success.
Safety Net Medical Home
The Patient-Centered Medical Home (PCMH) is a model of primary care delivery. In PCMH practices, patients receive well-coordinated services and enhanced access to a care team. Providers practicing in PCMHs use decision support tools, measure their performance, engage patients in their own care and conduct quality improvement activities to address patients' needs. The PCMH Model of Care has the potential to improve clinical quality, improve patient experience and reduce health system costs.
Robert Wood Johnson Foundation
Developed in collaboration with the RAND Corporation, the Robert Wood Johnson Foundation’s Culture of Health Action Framework sets a national agenda to improve health, equity and well-being. Informed by rigorous research on the multiple factors which affect health, it recognizes there are many ways to build a Culture of Health, and provides numerous entry points for all types of organizations to get involved.
Agency for Healthcare Research and Quality
The Agency for Healthcare Research and Quality (AHRQ) is the lead Federal agency charged with improving the safety and quality of America's health care system. AHRQ develops the knowledge, tools, and data needed to improve the health care system and help Americans, health care professionals, and policymakers make informed health decisions.
As many of these initiatives and approaches to change healthcare cross over, we at GCACH know our partnering providers are experiencing success through a variety of approaches and have been truly innovative in they way they implement them.