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Transformation Services providing technical assistance in meeting Track 1 requirements for advanced primary care, such as:
- Empanelment – calculating optimal panel size; monitoring continuity and panel management
- Access – evaluating operational considerations for 24/7 access
- Care Coordination – identifying high-volume/high-cost specialists; executing care coordination agreements with high-value providers
- Patient & Caregiver Experience – implementing Patient & Family Advisory Committee, including developing committee charter, planning logistics
- Optimal Use of Health IT – implementing CRISP tools (e.g., ENS alerts, query portal); establishing bi-directional connectivity
- Continuous Quality Improvement – ongoing monitoring of quality and utilization metrics; supporting process improvement; facilitating monthly quality meetings with practice staff
- Care Management Fee Investments – helping practices make best use of their portion of the care management fee
- “Fee-for-Value” Services – supporting implementation of services such as Medicare annual wellness visits, transitional care management, advanced care planning and collaborative care, to be billed by the practice
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TRACK ONE Services
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Technical assistance in meeting Track 2 requirements, including:
- Alternative Visits – evaluating feasibility and operational considerations for offering eConsultation, telephonic and/or group visits; monitoring and assessing impact of alternative care
- Self-Management – training staff in patient self-management support techniques; providing inventory of condition-specific self-management resources
- Health-Related Social Needs – providing social screening tool and inventory of local resources for social determinants of health (e.g., housing instability, food insecurity, transportation, financial vulnerability, health literacy, health-harming legal needs)
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