The Building Blocks of High-Performing Primary Care: Lessons from the Field

Rachel Willard and Tom Bodenheimer, UCSF

Seven primary care clinics share how they reframed their practices — shifting the focus from physicians to patients, and replacing a one-on-one approach with team-based care.

April 2012

With a shortage of physicians and no shortage of patients, a change is called for in how primary care is delivered in the United States. Some practices are meeting this challenge, shifting from the traditional physician-centered model to patient-focused teams, with the goal of improving access and quality of care.

The authors of this report visited seven primary care clinics to better understand how they adapted their practices to put the patient at the center. The report focuses on six building blocks of this new model of health care delivery:

  1. Data-driven improvement: Performance data are used in all corners of the organization to spur effective action.
  2. Empanelment and panel size management: Patients are assigned to a clinician, and clinics actively manage panel size, balancing capacity with demand.
  3. Team-based care: Teams comprised of clinicians, medical assistants, registered nurses, front desk personnel, and behaviorists are created, with all members responsible for the quality of care.
  4. Population management: Population management is used to address the needs of various subgroups of the patient population.
  5. Continuity and availability of care: Clinicians are required to work a minimum number of hours and days each week to ensure continuity of care, and front desk personnel are trained to encourage continuity in scheduling.
  6. Prompt access to care: Practices offer alternatives to in-person visits with a physician.

After these building blocks were put in place, these primary care practices reported increased satisfaction among patients and clinic staff, positive clinical quality metrics, and improved financial stability.

The complete report is available under Document Downloads.

Reader Comments

Great study. I would add it should not cost too much to build new information system to support these building blocks. EHR is part of it, but EHR alone is not sufficient. With modern web technologies, it's possible to embed the building blocks in a freely-available, open source technology platform.

http://code.google.com/p/pophealth-booster/