The resources below are designed to help your team and organization with the following topics:

  • Learning Organizations: Understanding adaptive and technical challenges. Communicating around large change initiatives. Clarifying leadership roles and how leaders work together to provide integrated care.
  • Team-Based Care 2.0: Delivering patient-centered care through redefining and experimenting with team roles and alternative visits, creating access and managing population health in a value-based care and payment environment. Standardizing care teams.
  • Planned Care and In-Reach: Gauging patients’ needs and delivering timely services and support, with an emphasis on leveraging technology, data tools for clinical decision making, and patient engagement strategies.
  • Proactive Outreach: Displaying and engaging the care team in using data, as well as the data systems for analytics and reporting. Partnering with health plans for data exchange. Considering risk stratification to enable effective outreach.
  • Behavioral Health Integration: Bringing behavioral health and somatic medicine together at the care team level to better detect illness, improve overall health outcomes, create a better patient experience, and reduce suffering.
  • Care Management for Complex Patients: Identifying high-risk patients. Defining interventions for patients based on strata. Integrating behavioral health. Building community partnerships. Managing hospital transitions.
  • Social Needs: Screening and prioritizing non-medical needs. Building internal systems, referral processes, and effective partnerships with community organizations to respond to identified needs.