The Transformed Practice: Coordinating the Continuum of Care

Posted by Finnah Pio, MS, CLSSBB on Mar 13, 2018 11:08:00 AM

Practice transformation is an ongoing process of developing a practice into a Patient-Centered Medical Home (PCMH)—a theoretical model of primary care delivery that is coordinated, team-based, and committed to achieving the Triple Aim of medicine.1 In today’s value-based healthcare environment, the Triple Aim guides practices to provide better care, achieve higher patient satisfaction, and lower healthcare costs per capita.

Successful Transformation to a PCMH

House with stethoscope - Medical Home.jpgPositive outcomes for a transformed practice correlate to the level of risk in the patient pool and the length of time the practice has been transformed.2 Since mature medical home programs tend to show stronger improvements in quality, utilization, patient engagement, and cost savings, the longer a PCMH has been in existence, the greater its chances for success.3

To be successful as a transformed practice, leadership, staff, and patients must work together to establish patient-centered workflows. When all invested parties—including patients—are engaged in achieving positive patient outcomes, a PCMH can provide higher-quality healthcare for its patients and their families.4


How Does Practice Transformation Achieve the Triple Aim?

Establishing an integrated care delivery system requires physicians and staff to build engaged relationships between every patient and the provider team. This integrated approach enables the transformed practice to achieve each of the three Triple Aim goals.

Elderly_Woman_with_Nurse.jpgTo improve patient experience, organizational leadership must request that all team members consistently practice at the top of their credentials. Leadership should encourage nurses, physician’s assistants, and staff to take on high-level tasks that offer support and alleviate routine tasks for physicians. Practicing at the top of licensure streamlines office workflows, reduces physician burnout, and creates an organized system that supports team-based coordination and care. Improving access (extended evening and weekend hours), implementation of telehealth, and a robust patient portal with secure messaging and scheduling capabilities are other examples of making a practice more “consumer-centric.”

Providers must also focus on providing quality care to high-risk patients to improve overall patient population health. To identify these patients, practices should invest in data management tools and develop an integrated analytics strategy for leveraging claims data.

By analyzing claims data, providers can identify high-usage patients and develop strategies for intervention and care coordination. Efforts can be made to ensure consistent physician visits and prevent avoidable emergency department (ED) utilization. Over time, coordinating care for high-risk and rising risk patients will provide the greatest opportunities to reduce healthcare costs per capita.

Navigating the Challenges of PCMHs

PCMHs provide the foundation for the ongoing journey toward practice transformation, but require a commitment to coordinated actions, at all levels. Every member of a PCMH must be engaged in coordinated care with a shared vision of a transformed practice.

Yet even with an engaged team, many practices find that consistently working toward the goal of transformation is difficult to maintain long term. Fortunately, the challenge of scaling coordinated processes, principles, and cultures of transformation can be made easier with the help of an experienced practice partner.5

Enlisting Support for Transformed Care

To excel as a transformed practice, PCMHs should adopt the structure of an established practice transformation workflow. Continuum Health works alongside clients to develop scalable workflows with specific, time-bound goals. These actionable steps include:

     • Reducing cost of care through ED readmits and ambulatory care inpatient stays
     • Improving point of contact relationships between staff and patients
     • Improving provider efficiency, workflow, and relationships with patients
     • Aiding with care coordination
     • Developing an integrated analytics strategy for leveraging claims data

Transformed practices achieve the Triple Aim through these ongoing improvements. By developing a coordinated care delivery system, practices increase the quality of care for patients, reduce the administrative burden on physicians, lower overall costs, and ultimately ensure greater patient satisfaction. For more information about how Continuum can help transform your practice or group, please contact David Burke, Enterprise Sales Executive, at or 856-701-6246.


1 Evidence Report Briefing on Capitol Hill
2 The Impact of Primary Care Practice Transformation on Cost, Quality, and Utilization
The Patient-Centered Medical Home's Impact on Cost and Quality: Annual Review of Evidence 2014-2015
5 The Impact of Primary Care Practice Transformation on Cost, Quality, and Utilization



Finnah Pio-798739-edited.jpgFinnah Pio, MS, CLSSBB, Director of Practice Transformation & Value Based Analyitics

As Continuum's Director of Practice Transformation & Value Based Analytics, Ms. Pio facilitates the integration of data, performance metric knowledge, and quality improvement methodology to enable clients to improve the health of their patient population. She works directly with the practice transformation team and collaborates with other Continuum departments to ensure clients can successfully achieve the Triple Aim of improved quality, improved patient satisfaction/engagement, and reduced overall cost of care.



Topics: Practice Transformation, Patient-Centered Medical Home, Triple Aim, care coordination, population health


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