Resource Library - Center for Care Innovations

Learning Organizations

Worksheet: Sustaining PHLN Innovations-Monitoring Key Organizational Areas (download Word version)

High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs: This IHI white paper presents three interdependent dimensions of high-impact health care leadership, including mental models, behaviors and frameworks.

Staff Satisfaction Survey: This staff satisfaction survey from Dartmouth Microsystems Primary Care Practice Handbook. Download the word document version.

How to Rally Your Team Around an Idea: CCI describes seven key steps to building support around an idea.

Leading Change Without Being Offensive: CCI offers thoughts about how to make change at an organization when that means disrupting what others hold dear.

Set Your Strategy – Chapter 2 Building a Data Driven Culture: These series of videos offer insights from thought leaders on how senior executives can tackle the big questions of making data use a central part of their organization’s strategy and goals.

Team-Based Care 2.0

Team-Based Care QI Tools: In the Team-Based Care for Emerging Leaders program, Dr. Carolyn Shepherd presented various QI tools that can be used to identify changes and support the continuous growth of organizations.

Building Workspaces for Team-Based Care: This summary describes how architects designed new building spaces for Clinica Family Health Services to facilitate team-based care.

Measuring Team Work: This document provides a variety of links to validated teamwork assessment tools.

Share the Care Worksheet – Assessment of Team Roles and Task Distribution: This planning tool helps you assess who is currently doing what tasks and how to distribute tasks amongst team members. Download the word version.

Team Planning Worksheet: This is a similar worksheet for assessing roles and responsibilities, from the Safety Net Medical Home Initiative. Download the excel worksheet.

Clinic Role Competency Assessments: These are examples from Clinica Family Health. They can be used to verify skill levels and useful for thinking about career ladders. This is another example of an MA competency assessment.

Nurse Position Description Examples: These are position description examples for different nurse roles at Clinica Family Health. Download the word document versions of position descriptions for Clinic Nurse, Nurse Team Manager, Nursing Services Manager.

Cambridge Health Alliance’s Model of Team-Based Care – Implementation Guide and Toolkit: This toolkit includes detailed steps on how to build a care team, descriptions of roles and responsibilities, tasks and associated team members, and huddle strategies and checklists. The toolkit also gives information about the structure of a care management program, diabetes management program, hospital discharge workflow, and more.

Integrating RNs Into Care Teams: This is an example from Serve the People Community Health Center.

Population Health Toolkit: This toolkit developed from CCI’s CP3 program has information on a variety of topics. Scroll down the page and click on the topic of “Building and Strengthening the Care Team” for a variety of resources.

Team-Based Care Principles and Values – Discussion Paper: This paper identifies and describes a set of core principles to help enable health professionals, researchers, policy makers, administrators, and patients to achieve appropriate, high-value team-based health care.

When Teammates Don’t Connect: Learning to Manage Interdependence: This paper discusses interdependence in teams; when members are mindful of the rest of the team’s needs and roles, and how they can affect each other’s ability deliver their best.

The 10 Building Blocks of Primary Care – Summary Information: This handout gives an overview of the Building Blocks and is useful for discussing with your team.

The 10 Building Blocks of High Performing Primary Care – Annals of Family Medicine: This paper goes into more detail about how the Building Blocks were developed and what each Block entails.

Tools for Transformation – The Center for Excellence in Primary Care provides practical instruments, activities, and resources to help you achieve the Quadruple Aim and use the 10 Building Blocks in your practice.

How Do You Measure Workplace Culture?: This CCI perspective reflects on how workplace culture can be measured and the value of doing so.

Innovator Highlight – Integrating Pharmacy Teams into Primary Care: The University of Southern California (USC) School of Pharmacy collaborated with AltaMed Health Services to provide comprehensive medication management (CMM) for patients with poor chronic disease control.

The Primary Care Team Guide: This website is a guide that provides step-by-step direction on how to establish high-functioning teams and implement new functions essential to team-based care.

Pharmacy Services Integration: This short video describes Share Our Selves health center’s integration of pharmacy services into comprehensive chronic disease care.

A Close Look at Medi-Cal Managed Care: Stories of Quality Improvement Success: This brief discusses interconnected strategies for success, as well as specific success stories, in improving HEDIS measures by managed care plans in California.

Planned Care & In-Reach

Exploring the Impact of Integrated Medicaid Managed Care on Practice-Level Integration of Physical and Behavioral Health: This brief and related infographic describes how integrated financing influences the coordination of physical and behavioral health services. It provides recommendations for how physical-behavioral health integration can be advanced in areas of data-sharing and quality measures, payment and business practices, and clinical practice and service design.

Population Health Toolkit: This toolkit includes tools, resources and learnings on topics such as team-based care, population health management, planned care, and data-driven decision making. Standing order set examples and protocols can be found and downloaded on pg. 13.

What it Takes to Provide High-Value Health Care: CCI offers updates to the 10 Building Blocks of Primary Care framework that it believes are critical to improving the health and wellbeing of populations.

Payment Innovation in FQHCs: Lessons from California: CHCS gives an overview of lessons learned from California’s APM Pilot.

Moving Toward Value Based Care: Payment Redesign Insights and Reflections: CCI shares insights, reflections, and recommendations that can inform your work, including an infographic.

Pre-Visit Planning: This webinar discusses planned care and using data and optimizing care team roles to improve pre-visit planning activities.

Building a Data-Driven Culture: A Video Learning Series: This video learning series will help you plan and navigate your data capacity-building journey and align your data strategy with your organizational strategy.

Building a Data-Driven Culture for Population Health Management: This webinar shares a framework and key capabilities for developing strong data processes and systems to improve care.

All About Empanelment: This video learning series covers the essentials of empanelment, from setting up patient panels to maintaining and maximizing them.

Empanelment Series: This webinar series discusses why panels are important, how to empanel patients, using the 4-cut method, and more.

Tech Demo – Multilingual Patient Engagement Tools: This is a demo of ConsejoSano, which helps payers, providers and employers increase engagement with multicultural populations by offering patient engagement solutions to drive value-based care outcomes.

Tech Demo – Connecting Providers to Patient Stories: This is a demo of Patient Wisdom, a platform for providers to learn about their patients’ stories, goals, and concerns in a matter of seconds.

Tech Hub Case Study – Timely Patient Feedback: San Francisco Health Network piloted Tickit, an electronic survey delivered via tablet (iPad) and text message.

To Switch or Not to Switch — That Is the Question: CHCS’s Senior Program Officer, Carlina Hansen, wrote a blog on the considerations that clinic leaders are reflecting upon before making the switch between EHRs.

Proactive Outreach

Innovation Spotlight – Lumiata’s Predictive Analytics Platform: This article spotlights San Mateo Medical Center’s partnership data science startup Lumiata to pilot their Snowflake platform. Snowflake provides predictive and prescriptive analytics that can both map an individual patient’s likely outcomes and identify population-level gaps in care.

Leveraging Data for Value Based Care: This video discusses how to use data and work with payers to support value based care.

Using i2iTracks: This webinar series demonstrates how to make population health data actionable for front-line staff and proactively engage patients using the tools available in i2iTracks. For more information about i2i, visit their website.

Using Your Analytics Ecosystem: This webinar reviews best practices to help you use your HIT analytics environment to better manage your hypertensive patients and meet your hypertension goals.

Patient Segmentation for Care Coordination:This webinar discusses risk stratification as an analytic method to identify patients most in need of care.

Behavioral Health Integration

Paying for Value in Behavioral Health – This CHCF paper explores lessons learned by three states (New York, Vermont, Tennessee) that have developed behavioral health VBP initiatives.

Behavioral Health Specialist: This gives an overview of the role of the behavioral health specialist on a care team. Explore the Action Steps and Tools & Resources tabs for additional information and resources.

Integrating Behavioral Health into Primary Care: SAMHSA-HRSA Center for Integrated Health Solutions provides resources and tools for how to integrate behavioral health services into primary care settings and care teams.

Pediatric Behavioral Health: This webinar discusses how to integrate behavioral health into pediatric primary care.

MIRAH Tech Demo: This webinar is a demo of MIRAH, a measurement-based care system that can improve a behavioral health department’s tracking of patient symptoms, measuring treatment progress, and using this data in patient visits to improve health outcomes.

Care Management for Complex Patients

Diabetes In Special & Vulnerable Populations Learning Series: This is a national learning series is focused on co-morbidities associated with diabetes.

Speaking the Language of Diabetes: This document provides recommendations for enhancing communication about and with people who have diabetes.

Chronic Care Management Codes Toolkit: This document details practices to implement and bill CCM codes.

Chronic Care Management Services Changes for 2017: These include services changes and CPT CCM codes.

Better Care Playbook: This Playbook offers guidance on identifying people with complex needs, case studies on promising approaches, information about the business case, and more.

Validation of the What Matters Index: This is a brief, patient-reported index that guides care for chronic conditions and can substitute for computer-generated risk models.

Interactive Complex Care Map: The Better Care Playbook and the Center for Health Care Strategies have developed a map of complex care programs and models across the country.

Care Neighborhood Case Study: Community Health Center Network tested Welkin Health, a modular patient relationship management platform, to enhance and streamline Community Health Workers’ workflows and allow them to reach out to patients most at risk.

Innovator Highlight – Inpatient/Outpatient Coordination: This article highlights ways to improve both sides of the discharge and coordination process.

Innovator Highlight – Mobile Care Transitions: Marin General Hospital partnered with ZynxHealth, a mobile based platform, to create the nation’s first mobile care transitions network.

Evidence-Based Care Transitions: San Francisco General Hospital and UCSF discuss how to build an evidence-based approach to improving care transitions.

Innovation Spotlight – RubiconMD Curbside Consults: Community Health Center Network piloted electronic curbside consults with tech company RubiconMD to better triage their complex patients’ specialty needs.

Chronic Pain Group Visits: Riverside University Health System developed a two-hour group visit aimed at helping patients manage chronic non-malignant pain.

Innovation Spotlight – Recuperative Care Housing: Central City Concern’s Recuperative Care Program seeks to catch medically, mentally and behaviorally complex homeless patients when they are discharged from the hospital.

Innovation Spotlight – Street Medicine: Tri-City Health Center’s street medicine program and HOPE Project van highlight two ways to bring care to individuals experiencing homelessness.

How Analytics Transform a Health Home Model: This case study discusses Contra Costa Health System’s ambulatory care model, Care Connect, that diverts high utilizers away from the ED and toward care that promotes their long-term health, with coordinated case management services at its center.

Innovation Spotlight – Behavior Change Solution: Northeast Valley Health Corporation and Petaluma Health Center both piloted Omada Health, which offers a digital platform that offers patient support groups, one-on-one coaching, online learning and connected devices. This is particularly useful for patients with chronic health conditions.

Blueprint for Complex Care: A Strategic Plan for Building the Field: Drawing from experts and frontline stakeholders across the country, assesses the current state of the complex care field and presents actionable recommendations to help the field reach its full potential.

A Flexible Framework for Effective Essential Needs & Social Health Initiatives – Health Leads has published a framework and curated library of tools, best practices, implementation guidance, and other dynamic content. Both of these are organized into six “drivers” that are key to successful social needs strategies in clinical settings.

How Understanding Trauma Can Strengthen Health Care Organizations: A Q&A with Sandra Bloom: CHCS recently spoke with Sandra Bloom, MD, associate professor at Drexel University’s Dornsife School of Public Health and co-founder of the Sanctuary Model, to better understand how trauma influences health care organizations and how organizations can strengthen care delivery through trauma-informed care.

Complex Construction: A Framework for Building Clinical-Community Partnerships to Address Social Determinants of Health: United Hospital Fund has released a framework designed to help primary care providers screen their patients for social determinants of health and partner with community-based organizations (CBOs) that can respond to those needs.

Community Resource Referral Platforms Guide: SIREN has developed a guide that explores the landscape of community resource referral platforms, the experiences of early adopters, features and functionalities of these technologies and lessons learned and recommendations on how to implement a community resource referral platform.

PRAPARE Implementation and Action Toolkit: This free toolkit contains resources, best practices, and lessons learned to help guide users in each step of the implementation process of using the PRAPARE tool, ranging from implementation strategies and workflow diagrams to Electronic Health Record templates and sample reports to examples of interventions to address the social determinants of health.

Social Determinants of Health Tools and Resources: This is a collection of tools and resources that Oregon Primary Care Association compiled, including on topics like screening and workflows, food insecurity, housing insecurity, integrating SDoH into clinical care, community partnerships and more.

Association for Academic Health Centers – SDoH Initiative: This website has a scorecard to measure your organization’s efforts to address SDoH, as well as related reports and resources.

Social Determinants of Health 101 for Health Care: HealthPartners Institute published this discussion paper about five things we know and five things health care organizations need to learn to address SDoH for the national quality strategy.

Pathways for Determinants of Health Poster: This downloadable poster diagram is a model of all factors correlated with health outcomes for an individual.

Caring with Compassion: The website supports health professionals who care for socioeconomically disadvantaged populations: homeless, uninsured, and underserved patients. It offers a curriculum that introduces the bio-psychosocial model for the provision of personalized care for at-risk patients.

Health Leads Collaborative for Advancing Social Health Integration Change Package: This change package is designed to guide participating health care delivery organizations through the process of addressing patients’ social needs as a standard part of quality care. It defines key drivers of success and recommended changes and strategies that, when implemented, will help teams improve quality and advance towards their aim.

Pathways Community HUB Manual: This is a guide to help those interested in improving care coordination to individuals at highest risk for poor health outcomes. The Pathways Community HUB (HUB) model is a strategy to identify and address risk factors at the level of the individual, but can also impact population health through data collected.

Poverty Screening Tool: This tool from Canada is a diagram for screening for poverty and steps primary care teams can take to intervene.

ROI Calculator for Partnerships to Address SDoH: This financial tool calculates the ROI from integrating social services with medical care. The calculator compares how the financial returns and risks could be divided between the cross-sectional partners (social service and medical) under a variety of payment arrangements and levels.

Innovation Spotlight – Using Social Determinants Data: Petaluma Health Center has refined its workflow to collect social determinants data using a waiting room kiosk, exam room questioning and their patient portal.

Innovation Spotlight – Emancipators Initiative for Former Inmates: Roots Community Health Center is giving formerly incarcerated Californians a fresh start — at home, in the workplace, and for their health.

Growing Deep Roots in Kalihi Valley: Learn about how Kokua Kalihi Valley (KKV) Comprehensive Family Services approaches their role as a health center supporting the needs of their community.

Tackling Institutionalized Racism: This perspective discusses health inequities and the ways in which our health care system intentionally and unintentionally perpetuates institutionalized racism.

Building Data Capacity & Community Health Collaboration: This case study describes West County Health Centers’ new model for community stakeholders to interact with community health data, as part of a larger movement towards community-based care transformation.

Optimizing the Flow of Information and Work for Social Needs: This webinar discusses how to integrate social needs information and work into current clinical settings, such as how to map workflows.

Using Data to Drive SDOH Priorities: This webinar discusses how Cincinnati Children’s Hospital uses data to identify and prioritize key social determinants of health to improve child health outcomes.

Tech Demo – Online Community Resource Directory and Referrals: This is a demo of Aunt Bertha, which makes it easy for people facing social needs – and those who help others – to find and make referrals to appropriate programs and services for food, shelter, health care, work, financial assistance and more.

Paying for Population Health: Case Studies on the Role of the Health System in Addressing Social Determinants of Health: This report focuses on four case study sites in Vermont, Michigan, Ohio, and South Carolina. Each case study includes a detailed description of the intervention, outlines enabling factors, and provides considerations for the future.

Addressing Social Determinants of Health through Medicaid Accountable Care Organizations: Early State Efforts: This webinar from The Commonwealth Fund explores early efforts to address SDOH through Medicaid ACO programs. This includes SDOH approaches that states are considering, including partnership requirements, social needs screening, referral, and service delivery, financial incentives, and quality metrics.

Public Health Field Guide: How to Engage Payers in Addressing Social Determinants of Health: This blog explores four approaches that state and local health departments have used to collaborate with payers to address social determinants of health.

Sustainably Financing Community Health: Where to Look, When to Pursue, and How to Access Different Sources of Capital Webinar: The Center for Community Investment and Quantified Ventures will discuss a range of key questions and alternative models intended to expand knowledge of, comfort level with, and capacity to take advantage of different financing options for multi-sector community work.

The ROI for Addressing Social Needs in Health Care Webinar Series:The California Improvement Network spotlights in-progress efforts of leading health organizations to accurately measure return on investment (ROI) for social needs that impact health.

Enabling Services Improve Access To Care, Preventive Services, And Satisfaction Among Health Center Patients: A new study from the UCLA and HRSA shows that patients that used services at health centers that address SDOH needs (e.g. care coordination, health education, transportation, food assistance, etc.) were more likely to visit a health center and get a routine checkup compared to patients that did not use these services.

Health Equity IHI Resources – Check out IHI’s resources that address what health equity is and why it matters, and achieving and improving health equity.

PHLN Support Portal

Learning Organizations

Team-Based Care 2.0

Planned Care & In-Reach

Proactive Outreach

Behavioral Health Integration

Care Management for Complex Patients

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