We support specialty care practices that participate in our Patient-Centered Specialty Care (PCSC) program through our Learning Collaborative Curriculum. The Curriculum consists of three modules in which health care professionals learn concepts through webinars, practice concepts using a PDSA cycle and then reinforce the concepts with PDSA worksheets.
Module 1: Implementing Care Compacts to Enhance Care Coordination
The first module focuses on the implementation of care compacts by the specialty practice to promote effective communication and improve care coordination within the medical neighborhood.
The Care Coordination section of the scorecard includes a component for engagement and participation in the CDT activities as described in the Learning Collaborative section. To complete Module 1, practices are expected to submit one PDSA worksheet focused on care coordination (i.e., enhancing referral process, establishing huddles and utilizing EMR).
Webinar | 1 hour
The objectives of this module are to understand the components of a care compact, define a good referral and establish practice-specific standards for elements within the compact in order to support a collaborative approach to providing comprehensive patient care.
Webinar | 30 minutes
This session focuses on implementation of care compacts within your medical neighborhood and is meant to be a working session. This presentation defines characteristics and desired qualities of high-functioning medical neighbors, as well as the importance of care compacts. Throughout this Virtual Office Hour, practices explore their medical neighborhood, identify potential collaborative practices to implement care compacts, develop an outreach plan and discuss potential implementation challenges.
Webinar | 30 minutes
This session focuses on the Plan-Do-Study-Act (PDSA) improvement model. Practices are introduced to the PDSA components and how to utilize these building blocks to conduct small-scale tests of change within your practice.
Topics covered include determining a patient- and family-centered area of focus for improvement within your practice, developing an aim statement to support achievement of your goals, reviewing the components and stages of the PDSA model, reviewing a sample PDSA and utilizing the model for improvement as a framework to guide your work.
Module 1 Tools and Resources
Improve care coordination within your medical neighborhood. Objectives include defining the components of the care compact, defining a good referral and establishing practice specific standards for elements within the compact.
Outreach to Primary Care Providers (PCPs)
Invitation Letter to PCP Partner
Recruiting and Engaging Medical Neighbors Worksheet
Recruiting and Engaging Medical Neighbors Provider-to-Provider Communication Presentation
Referral Process
Provider Referral Request Form
Cardiology Referral Preparedness Tool (Blank Template)
Example of Cardiology Referral Preparedness Tool
Endocrinology Referral Preparedness Tool (Blank Template)
Example of Endocrinology Referral Preparedness Tool
OB/GYN Referral Preparedness Tool (Blank Template)
Example of OB/GYN Referral Preparedness Tool
Enhancing Care Coordination Through Huddles
Improve Office Efficiency in Mere Minutes (Video)
Additional Resources
Reducing Waits and Delays in the Referral Process, Family Practice Management
Module 2: Clinical Quality and Appropriateness of Care
The second module focuses on specific actions that can be taken to improve the quality of care to patients and streamlining processes to improve HEDIS measure compliance.
The Care Coordination section of the scorecard includes a component for engagement and participation in the CDT activities as described in the Learning Collaborative section. To complete Module 2, practices are expected to submit one PDSA worksheet focused on clinical quality and appropriateness of care.
Webinar | 1 hour
This training provides valuable information to assist providers in improving the quality of care to patients and overcoming common obstacles to compliance. Participants will be provided with insights, success stories and specific actions that can be taken to improve and streamline processes for improved quality and quality measure compliance. After completing this activity, the participant will demonstrate the ability to: (1) identify methods to improve clinical documentation to demonstrate compliance; (2) discuss best practices for population health management with an emphasis on tracking and outreach; (3) collaborate with medical neighbors to close gaps in care, educate patients on the importance of preventative health measures and routine screenings; and (4) coordinate and leverage appointments to improve compliance.
Webinar | 1 hour
Objectives of this learning event include sharing best practices for closing gaps in care by leveraging practice data and tools, developing processes and a comprehensive approach to building a registry, implementing workflow and practice redesign to achieve the Triple Aim.
Module 2 Tools and Resources
Learn about population health management strategies, tracking and outreach, patient education and identifying methods to improve clinical documentation.
Clinical Quality and Appropriateness of Care
Module 3: Enhancing Efficiency of Care
The third module focuses on impacting the efficiency of care to actualize the Triple Aim of improved quality, increased patient satisfaction and lower health care costs.
The Care Coordination section of the scorecard includes a component for engagement and participation in the CDT activities as described in the Learning Collaborative section. To complete Module 3, practices are expected to submit one PDSA worksheet focused on enhancing the efficiency of care.
Webinar | 1 hour
This session focuses on impacting the efficiency of care to actualize the Triple Aim of improved quality, increase patient satisfaction and lower health care costs. Objectives include recognizing what cost of care means to stakeholders in the health care system and identifying cost effective, high quality solutions in health care choices that can lead to decreased cost, reducing waste and overuse.
Webinar | 30 minutes
This session is meant to help specialty care practices that are committed to delivering high-quality, cost-efficient, patient-centered care. The tools and resources discussed are intended to help specialists more efficiently manage patient care by guiding patients to services with proven success.
Webinar | 30 minutes
This session focuses on strategies and best practices for driving results and sustaining change. We discuss management of change fatigue and barriers to transformation. In addition, we explore the six components to sustaining practice transformation and elements of a sustainability plan.
Module 3 Tools and Resources
Enhance the efficiency of care you are able to provide your patients.
Enhancing the Efficiency of Care
AIM Specialty Health Solutions
Improving Medication Adherence
