Table 1

Chief Primary Care Medical Officer Functions and Roles

Starfield Primary Care FunctionCPCMO RoleMeasurable OutcomesSpecific Examples
Accessible PCP contactEnsure strong primary care bridge between acute and chronic care settingsIncreased 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 coordinationBuild systems that support improved bidirectional flow of information and effective clinical follow-upTimely 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 patientFacilitate collaboration between hospitalists, specialists, and PCP in care planning; Improve support for PCPs that enables them to successfully implement discharge plans
Ensure comprehensivenessFacilitate complete care for multiple comorbidities across the spectrumDecreased readmission rates; decreased length of stay in hospitalCoordinate with PCP and hospitalists to identify accessible services and referrals that hospitalized patient needs in order to facilitate comprehensive discharge planning
Maintain continuityEnsure inpatient and outpatient teams stay connectedSafer handoffs; improved patient satisfactionReinforce 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.