US Publications

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  • Care Management Summary - Colorado Team-Based Care Initiative Change Package Tool
    May, 2017 - Care Management Summary from the Team-Based Care Initiative Change Package Toolkit. Ensuring patients who are at high risk or have complex needs are well cared for during and between office visits. Download (PDF, 160 KB) ...
  • Redesigning Primary Health Care Teams for Population Health and Quality Improvement
    May, 2017 - Over a the-year period, Penobscot Community Health Care, a federally qualified health center in Maine, implemented a primary care transformation initiative that redesigned its care teams and their workflows. Under this “Delegate Model,” Penobscot physicians assign tasks that they used to perform to trained care team medical assistants (CTMAs). The ...
  • Rising Risk: An Overview of Identification and Intervention Approaches
    January, 2018 - This brief, produced with generous support from Blue Shield of California Foundation, explores the concept of rising risk in the health field. Given that it is well understood that a small group of “familiar faces” consume a disproportionate percentage of healthcare resources (the top 5% of patients are responsible for ...
  • Team Based Care: Joy in Practice
    March, 2018 - Examples to ensure all staff find meaning and fulfillment in their work while removing impediments to joy and preventing burnout Download (PDF, 146 KB) ...
  • Using Data to Manage Population Health Under Risk-Based Contracts
    June, 2017 - With value-based care, providers are increasingly being asked to take on more accountability, and in some cases financial risk, for cost and quality outcomes for a defined population. By reviewing this document, health centers can assess whether they are investing sufficiently in the clinical and administrative infrastructure and analytics to ...
  • What is value-based payment and why are health centers considering payment reform?
    2016 - Many health centers are at the crossroads of needing to invest in updating their care model so they can engage in the evolution of the health care system, and maintaining financial sustainability in what remains largely a fee-for-service world. By helping to shape value-based payment models in their services areas, ...