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Transformation and its Core Elements

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At the heart of medical home transformation is a core set of elements which position a primary care practice to maximize its return on effort investment—returns characterized by making progress in sustainable change that favorably impacts patient experience, quality outcomes, and total cost of care. Some of these “Core Elements” point to engaged practice leadership, embedded use of QI methodology including incorporation of data use to drive change, and shifting the practice delivery paradigm to a team-based model where all team members have a role in providing efficient, patient-centered care that is appropriate to that team member’s level of training.  
The following Program Milestones and Indicators of Progress are drawn from industry best practices and our current understanding of determinants for practice success in medical home transformation. They are intended as guidelines to inform interpretation of primary care practice progression through the program. 
The Medical Home Monitor is designed to evaluate your practices’ status related to the foundational concepts and characteristics of a patient-centered medical home. The objective is to obtain a baseline status of these foundational areas which will inform our work together as future assessments are obtained. 
First in a series of Commonwealth Fund-authored health care reform publications appropriate for the lay population. Focuses on the role of Primary Care and the patient-centered medical home. 
This paper describes a five-part vision from IHI for the way health care leaders can bring the health care system to its ideal state. 
This paper describes some of the most powerful tools and strategies employed by leaders who are most successfully improving health care. 
This collection from California HealthCare Foundation (CHCF) of case studies describes ways that primary care providers have shaped effective teams for high-functioning practices. 
This paper outlines the reasons a team-based primary care approach is necessary to address the limitations of physicians’ time and resources, and discusses some important elements of successful teams. 
This guide to team-based care describes the importance of the team-based approach under a patient-centered care model, how to establish and sustain a care team, and offers one case study of a successful team. 
This paper describes common elements of Group Health’s Chronic Care Management model and the Patient-Centered Care model. These overlapping principles point the way to planning and delivering care in a way that follows the best available clinical evidence. 
This white paper from the Institute for Healthcare Improvement (IHI) identifies the weaknesses of the traditional primary care system and describes a way to overhaul it, leading to improved patient experience and better outcomes. 
This review of results from an 8-year project describes lessons learned by 13 organizations that strove to achieve “perfect” outcomes. The lessons include the importance of leadership as an organization undergoes systemic change.  
This white paper from IHI describes 13 carefully developed metrics by which to gauge the success of a hospital, a community or a large health care organization. 
This paper describes how the IHI developed the Framework for Spread, a process by which innovation can go from small to large-scale adoption. 
This white paper from IHI describes the challenges and some of the best practices around taking isolated health care innovations to a broad – or ubiquitous – scale. 
This paper from IHI focuses on not just identifying problems with the status quo or envisioning solutions, but in how to actually make change happen on a systemic scale. 
This webinar features IHI’s Executive Director of Performance Improvement, Robert Lloyd, PhD, describing best practices for collecting clinical data and improving outcomes.  
This project planning form offers one way to organize a specific project in the practice and care transformation process. 
This book by Suzanne Houck describes some health care organizations’ successful efforts to improve patient outcomes, physician satisfaction and reach operational success. 
HealthcareCommunities.org (HC) is a web-based knowledge management system that provides multiple means for the healthcare quality improvement community to share knowledge and contribute to each other’s QI work. Visit the HC Resource Center for documentation, tools and resources related to healthcare quality improvement. 
HealthcareCommunities.org (HC) is a web-based knowledge management system that provides multiple means for the healthcare quality improvement community to share knowledge and contribute to each other’s QI work. Visit the HC Resource Center for documentation, tools and resources related to healthcare quality improvement. 
The American College of Physicians (2013) offers a position paper that describes principles, definitions and examples which provides a framework for an updated approach to health care delivery that can be useful to clinical teams (made up of physicians, advanced practice nurses, physician assistants, RNs, clinical pharmacists, and other allied health care partners) in organizing care processes and clinician responsibilities. 
Link to the PCPCC-hosted "Strengthening the Primary Care Workforce" database--a searchable online database of nearly 100 training programs from academic and training institutions, from across the US, that supports student, resident, clinician and other health care professional pursuit of skill development in delivering primary care that is patient-centered and collaborative. 
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