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Patient-Centered Primary Care Program – Provider Toolkit

Transformation and Its Core Elements

At the heart of medical home transformation is a core set of elements that position a primary care practice to maximize its return on effort investment. These returns are 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:

Program milestones

You may recognize that our program milestones closely mirror the program expectations described in Appendix A of your Program Description and contract. The milestones are founded on industry best practices drawn largely from the data we now have as a result of the many medical home pilots that have been implemented across the nation – many of which we have directly participated in or supported. While the milestones help to frame program expectations, there are associated indicators that we’ve defined that will help you to:

About our Provider Toolkit resources

Our “Provider Toolkit” is offered to you as just one of the many resources that accompany our Patient-Centered Care Program to support your achievement of success as you journey through the changes asked for by this program. It’s framed by our 10 program milestones and contains:

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.

Provider Toolkit Resources for the Patient-Centered Primary 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.


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