Table 1

Chief Primary Care Medical Officer Functions and Roles

Starfield Primary Care Function	CPCMO Role	Measurable Outcomes	Specific Examples
Accessible PCP contact	Ensure strong primary care bridge between acute and chronic care settings	Increased involvement of primary care function in acute care setting Improved communication including better understanding of primary care resources	Develop computerized networking systems to help match PCPs with patients needing care. Be a “match maker” based on expert knowledge of PCPs in the community; Promote hospitable environment for PCPs on hospitalist teams to increase PCP input
Care coordination	Build systems that support improved bidirectional flow of information and effective clinical follow-up	Timely and safe hospital discharges; patient-centered transitions to optimal location after hospital discharge; Confirmation of timely connection between inpatient and outpatient care teams for every patient	Facilitate collaboration between hospitalists, specialists, and PCP in care planning; Improve support for PCPs that enables them to successfully implement discharge plans
Ensure comprehensiveness	Facilitate complete care for multiple comorbidities across the spectrum	Decreased readmission rates; decreased length of stay in hospital	Coordinate with PCP and hospitalists to identify accessible services and referrals that hospitalized patient needs in order to facilitate comprehensive discharge planning
Maintain continuity	Ensure inpatient and outpatient teams stay connected	Safer handoffs; improved patient satisfaction	Reinforce central role of PCP and consistency of PCP relationship with patient across shift changes and discharge transitions; Monitor Neighborhood Stress Scores (NSS7)³³ in order to optimize systems of primary care

CPCMO = chief primary care medical officer; PCP = primary care physician.