| 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 |