Table 1.

A Few Parsimonious Enablers and Tenets of Primary Care Transformation

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.