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Core Attribute Description Access Patients get the care they need when they need it Accountability Clinics are responsible for making sure patients receive the best possible care Comprehensive, whole-person care Clinics provide patients all the care, information, and services they need Continuity Clinics work with patients and their community to improve patient and population health outcomes over time Coordination and integration Clinics help patients navigate the system to meet their needs in a safe and timely way Patient and family centered Patients are the most important members of the health care team and are ultimately responsible for their overall health and wellness Geography Size (Full-Time Equivalent, FTE) Ownership/Affiliation Practice Specialty Region Rural 5 ≤2 FTE primary practitioners 1 Independent and unaffiliated with any other clinics 12 Family Medicine 14* Columbia Willamette 11 Urban small 4 3 to 5 FTE primary practitioners 4 Independent and part of an alliance of clinics 1 Internal Medicine 3* Cascades East 2 Urban medium 6 6 to 9 FTE primary practitioners 5 Owned by a larger health system 7 Pediatric 4 Oregon Pacific 6 Urban large 5 ≥10 FTE primary practitioners 10 Northeast Oregon 1 ↵* One clinic specialized in both family medicine and internal medicine.
Key Challenge Strategy Shifting patterns of care use • Expanding access through teams, schedules, and staffing • Preventing unnecessary emergency department visits through patient outreach and emergency department information exchange • Ensuring care with outside providers through improved communication and referral tracking Fidelity to the PCPCH model • Prioritization of select standards and metrics • Implementing patient-centered practices including bilingual/bicultural staff, cultural competency training, and new population demographic metrics • Developing new continuous improvement capacity through committees, training, and clinic “champions” Refining care processes • Incorporating screenings, preventive services, and chronic disease management • Standardization of workflows • Customizing electronic health records for communication and reporting • Integration of mental health PCPCH, patient-centered primary care homes.
