Table 2. Delaware State Innovation Plan 9 Capabilities of Primary Care Practices.

Panel management	Understanding the health status of the patient panel and setting priorities for outreach and care coordination based on risk. Practices define and identify the highest-risk members of the patient panel. Providers develop and execute on an outreach plan for identified high-risk patients. The practice prioritizes these patients for care coordination, appropriate care interventions, and self-management education.
Access improvement	Introducing changes in scheduling, after-hours care, and/or channels for consultation to expand access to care. Providers develop and implement approaches to expanding access to care, and adapt based on identified patient needs and preferences. Approaches to expanding access may include after-hours and same-day appointments, phone consultations with licensed health professionals, and consultation by email, text or other technology.
Care management	Proactive care planning and management for high risk patients. Practices identify high-risk patients, develop team-based interventions to deliver appropriate care, coordinate resources external to the practice when necessary, and track progress. Providers use information on patients’ health risks and tailor responses accordingly.
Team-based care coordination	Integrating care across providers within the practice, across the referral network, and in the community. Practices identify a multi-disciplinary care team that may include physicians, nurses, medical assistants, pharmacists, social workers, and other clinical staff. Practices coordinate activities and promote communication across the team involved in a patient’s care and integrate specific approaches for this collaboration into their operating model (e.g., by setting up case conferences). Practices also develop systems to coordinate with external stakeholders, such as outpatient specialists, hospitals, emergency rooms and urgent care centers, rehabilitation centers, community resources, and the patient’s support system. Coordination improves care planning, diagnosis and treatment, management through transitions of care, and patient coaching to improve treatment adherence. This capability includes integration of primary care practices with behavioral health providers where possible.
Patient engagement	Outreach, health coaching, and medication management. Practices develop a culture centered on understanding and responding to patient needs. Further, practices offer patient engagement tools and self-management programming. Approaches may include patient education, incentives, and/or technology enablement. Practices develop and execute on patient engagement plans focusing on high-risk patients in particular.
Performance management	Using reports to drive improvement and participation in value-based payment models. Practices integrate a performance management approach into their daily operations, building on Delaware’s Common Scorecard. Performance management involves tracking relevant metrics, utilizing performance measurement data to inform, design, and/or improve interventions; and developing a culture of continuous improvement.
Business process improvement	Budgeting and financial forecasting, practice efficiency and productivity, and coding and billing. Practices implement business management and financial planning processes required to participate in incentive payment structures and shared savings models. Practices incorporate budgeting and financial forecasting tools to: 1) develop quarterly and annual budgets; 2) forecast resource allocation required to operate during and after transformation; and 3) estimate financial impact of incentive payments. Practices may consider making structural changes in their workflows to ensure efficient, productive team-based care delivery. Practices also adjust billing and coding processes where necessary to support transformation, including reporting requirements for performance measurement on the Common Scorecard.
Referral network management	Promoting use of high-value providers and setting expectations for consultations. Practices seek out timely information on providers that are part of their patients’ extended care teams from open sources as well as Delaware stakeholders (e.g., health systems, payers, other practices) to identify providers that deliver care consistent with the goals of the Triple Aim. Practices regularly strengthen the performance of their referral network through a number of approaches that may include, for example, setting clear expectations for partners, and establishing and tracking performance metrics.
Health IT enablement	Optimize access and connectivity to clinical and claims data to support coordinated care. To coordinate care, practices use health IT tools, including electronic health records, practice management software, and data from DHIN. Practices effectively interpret data, use health IT as a component of their workflow, and support expansion of the Community Health Record with clinical data.