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later, there is a crisis within the primary care specialty and no improvement in primary care access for Delawareans. While there may be a myriad of factors that have led to this state within primary care, including greater administrative burden, loss of has recognized the need for a comprehensive, data-based analysis with feasible, useful recommendations, which may impact
state and public policy to strengthen, support, and advance a sustainable foundation for primary care in Delaware.
This initiative will focus on workforce trends, utilization and patterns of care, and prioritization of high-impact levers in
both public and private sectors, which potentially may address gaps in care, as well as be inclusive of payment reform. DHCC and DCHI will collaborate on the initiative and work with a broader stakeholder group, including consumer advocacy groups, medical students, residents, and other health care professionals, both independent and within health care systems. The broader stakeholder group will provide feedback and information through a roundtable forum and a series of meetings by a smaller
1. Identify 5% of panel that is at the highest risk and highest priority for care coordination
• PERFORMANCE: Person-Centered Care Population Management Stratify Risk
a. The practice has a systematic process and documented criteria for identifying highest-risk patients (as it best suits the unique practice needs and goals (National Committee for Quality Assurance [NCQA] Patient-Centered Medical Home [PCMH])
b. The practice has established documented data sources
and data-handling processes to identify the highest-risk patients. Potential sources of data include claims information, electronic medical records, practice management systems, staff recommendations
c. The practice successfully updates its documented list of the top 5% highest-risk patients at least semi-annually (NCQA PCMH)
2. Provide same-day appointments and/or extended access to care
• PERFORMANCE: Person-Centered Care Enhanced Access Meet Patient Scheduling Needs
recommendations will be developed by an executive committee and submitted to DHCC.
As health care transformation continues to hurtle into the 21st century, DHCC will continue to engage public and private stakeholders and provide innovative, sustainable policy with the goal of improving the health of all Delawareans through quality accessible care.
HMA contacts for the BHI initiative:
• Nancy Jaeckels Kamp at nkamp@healthmanagement.com • Lisa Whittemore at lwhittemore@healthmanagement.com
CONTRIBUTING AUTHOR
■ NANCY FAN, MD is a practicing OB/GYN with Women to Women OB/ GYN at Saint Francis Healthcare in Wilmington, Chair of the Delaware Health Care Commission and Past President of the Medical Society of Delaware.
(QI) Optimal Use of Health IT (HIT) Innovate for Access
for reserving time for same-day appointments and appointments outside its typical daytime schedule (NCQA PCMH)
b. The practice has a process for informing patients/families about the role of the Advanced Primary Care Practice and gives patients/families materials that contain the instructions for
c. The practice collects patient experience and satisfaction data on access to care and uses these data to develop an access improvement plan (Centers for Medicare & Medicaid Services [CMS])
3. Implement a process of following up after patient hospital discharge
• PERFORMANCE: Person-Centered Care Coordinated Care Delivery Manage Care Transitions
• PERFORMANCE: Person-Centered Care Practice as a
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Del Med J | May/June 2018 | Vol. 90 | No. 5
DELAWARE PRACTICE TRANSFORMATION MILESTONES, GOAL-MAPPING, AND ASSOCIATED SUB-CRITERIA
