Practice transformation network that works with PeaceHealth-employed clinicians in implementing team-based care models within the practices. Teams work in tandem to integrate clinical findings, health metrics data, and chronic disease registry outcomes in a shared effort to identify high-risk populations, validate success of interventions, and determine opportunities for further intervention. Goals include:
- Improving clinical outcomes
- Improving overall health of individuals and communities
- Preventing unnecessary health expenditures
N/A
Medicare Physician Quality Reporting System (PQRS)-eligible professionals, critical access hospitals, federally qualified health centers (FQHCs), fee-for-service clinics, and PeaceHealth providers that do not already belong to a Medicare Shared Savings program (MSSP, CPCI, etc.)
(note: Individual clinicians enrolled in this TCPI network may not enroll in another TCPI network)
- Participate in practice assessments every six months
- Share monthly clinical and outcome results
- Attend national and local training webinars and PTN-led events
- Actively engage in implementation of “best practices” strategies
- Commit to system-wide standardization of “best practices” as developed
- Onsite, community-specific process improvement and change management support
- Centralized support for billing and data quality reporting
- Care coordination resources to help manage patients with chronic diseases, and social/economic and behavioral health needs
- Implementation of an integrated, system-wide electronic medical record (EMR) to improve communication and coordination of care across settings
- Assistance moving toward alternative payment models (APMs)
Eric Blake, EBlake@peacehealth.org