Table 4. Advanced Primary Care Components in Clinical Improvement Initiatives
Identification of high-morbidity, high-need patients; medical record review
Patients invited to participate in multidisciplinary group visits, assembled by ZIP code
Nurse care management
Pharmacist review for high-morbidity patients; also trigger of 10 or more meds
Care transition management for hospital and emergency department visits
Targeted patient experience surveys to determine chief reasons for visits to emergency department and urgent care center
Process improvements to patient flow through family health center
Process improvements in patient telephone access
Education and assistance with maintaining health plan enrollment
Close integration of practice clinicians with advanced primary care project initiatives
Group visits for patients with intense medical and social needs