A Few Parsimonious Enablers and Tenets of Primary Care Transformation
| System-level enablers |
| Payment reform |
| Practice facilitation |
| Data use and aggregation |
| More usable EHRs |
| Practice-level tenets |
| Build whole change together |
| Focus on large-scale, long-term change to become the practice that you want to be for your patients and your staff |
| Enlist everyone in the practice in the effort, including patients, families, and communities |
| Use facilitators and facilitation strategies |
| Change as a community, region, or system when possible |
| Find the right financial payment model and structural support for long-lasting change |
| Pace yourself |
| Do not work too fast on too many things, but also do not work only on marginal changes that do not matter |
| Sequence the change, starting with leadership, practice culture, and empanelment. Then move to other features of team-based care and coordination |
| Build adaptive reserve and work on maintaining joy of practice |
| Allow enough time to pass before passing judgment |
| Focus on what matters most |
| Explicitly target the most beneficial primary care outcomes or functions to for patients and communities, such as: |
| Building long-term relationships |
| Risk-stratified care management for high-need patients |
| Key chronic diseases such as cardiovascular disease and diabetes mellitus |
| Beneficial preventive measures (ie, immunizations, smoking cessation, colorectal cancer screening) |
| Integrated behavioral health |
| Social needs identification and resource connections |
| Save the rest for another day—work on what matters most now |
| Practice regular “quality improvement hygiene” |
| Meet regularly as an entire team to review change |
| Set targets and review progress toward those targets |
| Use registries of electronic clinical quality measures (do not wait for old and often inaccurate claims quality data) |
| Use an established quality improvement method—try changes and learn from them |
| Involve patients and your community in the change upfront and throughout |
EHR = electronic health record.