Patient- and family-centered care (PFCC) literature is growing, but few reports present patient, caregiver, and practitioner perspectives about care coordination in a team-based model.  "Function of the Medical Team Quarterback: Patient, Family, and Physician Perspectives on Team Care Coordination in Patient- and Family-Centered Primary Care", published in the December 2019 issue of The Permanente Journal,  investigates the function of the medical team quarter

"Measuring attributes of team functioning in primary care settings: development of the TEAMS tool", co-authored by Michael Parchman, Brian Austin, and Ed Wagner, describes the development of a new survey that gauges staff perceptions of team culture.  The TEAMS tool is part of our RWJF Learning from Effective Ambulatory Practices (LEAP) project.

Our Healthy Hearts Northwest study brought practice facilitators to over 200 small- and mid-size primary care clinics throughout the Pacific Northwest that sought to improve cardiovascular care to their patients. To help survey the landscape in each clinic, we developed the QICA (Quality Improvement Capacity Assessment).

Team-based clinic redesign of opioid medication management in primary care: effect on opioid prescribing, published in June 2019, describes the implementation of an innovative program and study led by Michael Parchman that was designed to help small rural clinics more effectively and safely care for patients living with chronic pain.  The 6 Building Blocks approach, described in this publication, is a promising, evidence-based intervention that leverages the power of primary care practice facilitators. 

The Toolkit for Clinical Quality Metric Extraction was created by the Healthy Hearts Northwest project as a guide for practice facilitators and primary care clinic staff in using health information technology to support quality improvement. Current as of April 2019, this toolkit was created to be used as a step-by-step guide for quality improvement reporting for any Clinical Quality Measure (CQM).  Topics include:

Developing Emerging Leaders to Support Team-Based Primary Care, a new paper co-authored by Katie Coleman, Ed Wagner, et al, describes the12-month Emerging Leaders program from our Learning from Effective Ambulatory Practices (LEAP) initiative.  A prototype for how interdisciplinary training targeting frontline staff might be implemented, the Emerging Leaders training included didactic content, mentorship, applied peer-to-peer learning,

In "A Guide to Integrating Cost-of-Care Conversations into Workflow", Nora Henrikson, PhD discusses three pathways that clinicians can use to best integrate cost of care conversations into their clinical workflows. Support for this podcast was provided by the Robert Wood Johnson Foundation and the New York State Health Foundation.

Integrating whole-person behavioral health care in primary care settings is one critical function addressed in our September 2018 publication, “From Goals to Operations: Approaches to Behavioral Health Integration at High-Performing Primary Care Practices." This paper describes how teams address the tasks specifically associated with optimized behavioral health care.

"How Do Innovative Primary Care Practices Achieve the Quadruple Aim?", by Ed Wagner, Katie Coleman, et al, presents findings from 38 high-performing practices that can help guide  practices, payers, and policy makers in understanding more specifically how improved PCMH outcomes can be achieved. It describes the execution of 8 functions in these primary care settings that collectively meet patient needs, which include managing populations, providing self-management support coaching, providing integrat

The Quality Improvement Change Assessment (QICA) is an assessment developed by Healthy Hearts NW for use in our project to introduce team members to the high leverage changes guiding our technical assistance approach, and to assess the current capabilities of enrolled practices. "Completing and scoring the QICA" provides instructions on using this tool.