Care Models, Clinical Operations, and Population Health

Print Friendly, PDF & Email

Organizations and providers are rising to the challenge of taking an increasingly active role in their patients’ clinical and psychosocial needs — often beyond their traditional training and organizational scope. PCDC’s Clinical and Quality Partners team works with primary care providers and practices nationwide to improve health outcomes by implementing new, effective, and cost-saving efficiencies — and to collaborate better with the patients and communities they serve.

Request Service Info

Care Coordination and Care Management

Care coordination maximizes the value of care by assuring that the patient’s needs and preferences are known and addressed across providers and settings. Providers who practice good care coordination will reduce fragmentation of care; help patients access timely, appropriate care; and help patients fully engage in their care.

PCDC offers:

  • Care Coordination training to develop the skills needed for comprehensive, efficient, and coordinated care
  • Coaching and Technical Assistance to implement operations and processes that efficiently manage and engage care between providers and patients

Integrating Telehealth and Other Remote Options

Many vendors, EMR platforms, and apps offer patients access to their providers. However, making those platforms work as a real alternative to in-person access can be challenging. PCDC staff can help:

  • Assess workflows and scheduling practices so that telehealth operations fit within normal business
  • Understand rules and regulations impacting remote access for patients
  • Support efforts to encourage patient portal enrollment

Current guidance for telehealth during the COVID-19 pandemic is available here.

Integrating Behavioral Health and Primary Care

Integrating primary care and behavioral health (including substance use services) is imperative for patient-centered, whole-person care. PCDC helps providers and teams deploy the highest-standard techniques to address common yet disabling conditions at the intersection of behavioral health and chronic disease, including depression, substance use disorders, chronic pain, diabetes, trauma, and more.

PCDC offers:

  • Customized trainings for motivational interviewing; trauma-informed care; screening, brief intervention, and referral to treatment (SBIRT); and integrated care workflows and competencies. Details are available here.
  • Technical assistance on co-locating practices, integrating new providers into practices, and improving access to new services

Addressing Social Determinants of Health

Communities, patients, and families face continuous barriers to good health, including access to housing, food, employment, and education. New rules and regulations are incentivizing providers to screen for social determinants, but challenges persist in to connecting patients to the appropriate social services.

PCDC offers:

  • Customized trainings for frontline staff on understanding the impact of social determinants and addressing social needs
  • Assistance for systems and practices in designing programs that address social needs and foster collaboration with social service and community organizations

Managing Population Health

A renewed emphasis on population health expands focus from solely the individual patient to larger cross-sections such as communities, practices, or panel subsets. To that end, government programs and insurance incentives are focused on demonstrable improvements in HEDIS, utilization, and other performance measures.

PCDC can support:

  • Customized technical assistance and coaching to improve the use of electronic health records and registries, introduce chronic disease management programs, and develop new care coordination and transitions of care programs
  • Training and technical assistance around chronic disease management