The Provider Toolkit also includes important UniCare-specific documents that your practice will find helpful as your team begins to actively participate in our Patient-Centered Care Program.
Milestone 1: Care Coordination – Resources, including toolkits and papers, to support the creation of internal infrastructure to coordinate care.
Milestone 2: Risk Stratifying Populations – Resources, including UniCare materials, to help you establish processes and workflows to utilize reports and MMH+ for population health management and high-risk patient stratification.
Milestone 3: Care Planning – Care planning templates and resources to support establishing a reasonable process in your practice for shared care planning that incorporates self-management support, goal setting and action planning.
Milestone 4: Population Health Management and Registries – Population health registry guides and other materials to help you set up and maintain a registry and use its functionality for patient outreach, closing gaps in care and managing prevention and the chronic disease needs of patients.
Milestone 5: Health Information Technology – Materials to help your practice maximize EHR or other available HIT for evidence-based care delivery and relevant clinical decision support.
Milestone 6: Patient-Centeredness – Methods to engage your patients and support your practice in transitioning to a culture of patient-centered care.
Milestone 7: Enhanced Access – Resources to establish expanded office hours, cross-coverage arrangements after hours, and online communication and visits for your patients within the patient-centered care model.
Milestone 8: The Medical Neighborhood – Resources to support the setting up of external processes and infrastructure to sustain coordination of care outside of the medical home.
Milestone 9: Improved Clinical and Utilization Outcomes – Program metrics, report how-tos, and options for helping patients to decrease the ineffective and unnecessary use of clinical resources are all examples of supports available to help you achieve improved clinical and utilization outcomes.
Milestone 10: Medical Home Recognition and Other Advanced Activities – The American College of Physician’s Practice AdvisorSM and other related resources provide your practice with additional PCMH content to help you achieve Level III NCQA recognition as a medical home, a strongly encouraged, but optional milestone.