Table 1.
System-level enablers |
Payment reform |
Practice facilitation |
Data use and aggregation |
More usable EHRs |
Practice-level tenets |
Build whole change together |
Focus on large-scale, long-term change to become the practice that you want to be for your patients and your staff |
Enlist everyone in the practice in the effort, including patients, families, and communities |
Use facilitators and facilitation strategies |
Change as a community, region, or system when possible |
Find the right financial payment model and structural support for long-lasting change |
Pace yourself |
Do not work too fast on too many things, but also do not work only on marginal changes that do not matter |
Sequence the change, starting with leadership, practice culture, and empanelment. Then move to other features of team-based care and coordination |
Build adaptive reserve and work on maintaining joy of practice |
Allow enough time to pass before passing judgment |
Focus on what matters most |
Explicitly target the most beneficial primary care outcomes or functions to for patients and communities, such as: |
Building long-term relationships |
Risk-stratified care management for high-need patients |
Key chronic diseases such as cardiovascular disease and diabetes mellitus |
Beneficial preventive measures (ie, immunizations, smoking cessation, colorectal cancer screening) |
Integrated behavioral health |
Social needs identification and resource connections |
Save the rest for another day—work on what matters most now |
Practice regular “quality improvement hygiene” |
Meet regularly as an entire team to review change |
Set targets and review progress toward those targets |
Use registries of electronic clinical quality measures (do not wait for old and often inaccurate claims quality data) |
Use an established quality improvement method—try changes and learn from them |
Involve patients and your community in the change upfront and throughout |
EHR = electronic health record.