Our current work proceeds directly from our early emphasis on activated patients and proactive practice teams

We continue to aim to better understand and inform the state of the art in high-functioning primary care teams. Recent work has included visiting innovative primary care teams across the U.S. to learn how care is being delivered by teams in new ways.

An effective primary care workforce is essential to better health and health care for all

To date, academic studies that examine primary care staff, training, and team functioning are still relatively scarce.  Many organizations recognize the need to revamp their workforce, and are experimenting with innovative team structures and role definitions.

Transforming primary care: healthier patients, happier staff

We know transformation of any kind is hard work.  That's why we created the Improving Primary Care Team Guide through our PCT-LEAP work.  An online tool for primary care teams, The Team Guide helps build high-functioning teams and provides practical, hands-on tools—easy to use, actionable and measureable.


Related Resources

Assessing quality improvement capacity in primary care practices

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.

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. 

Toolkit for Clinical Quality Metric Extraction

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

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,

A Guide to Integrating Cost-of-Care Conversations into Workflow

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.

How Do Innovative Primary Care Practices Achieve the Quadruple Aim?

"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

Completing and Scoring the QICA

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.

Partnering to Succeed: How Small Health Centers Can Improve Care and Thrive Under Value Based Payment

How can small health centers contribute to a sustainable primary care safety net that achieves better care, better health, lower costs, happier staff, and reduced health disparities? They can partner to succeed. Read our March 2018 publication co-authored by JSI Research &Training, Inc.: Partnering to Succeed: How small health centers can improve care and thrive under value-based payment.

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