Our Primary Care Learning Solutions Services

The evolving national healthcare landscape presents tremendous opportunities and challenges to primary care providers who are expected to improve health outcomes and patient experience while containing healthcare costs. Success in this dynamic environment requires practices to maximize their care teams, provide comprehensive care management and coordination, manage population health, and efficiently use health information technology (HIT) to support patient-centered care delivery. PRHI recognizes the challenges that many primary care practices face in mobilizing for a value-based healthcare environment: limited infrastructure for continuous improvement, limited knowledge and skills related to new care delivery models, and insufficient expertise using HIT and gathering and analyzing data to drive improvement.

To address these challenges PRHI has developed a range of services to support primary care providers, administrators, and staff in enhancing knowledge and skills to provide high value, patient-centered care. Our team of skilled trainers and coaches has expertise in a variety of areas including:

  • Quality improvement methodology, including workflow assessment and workflow redesign
  • Patient-Centered Medical Home (PCMH) implementation
  • PCMH recognition through the National Committee for Quality Assurance
  • EHR implementation and optimization
  • Behavioral health and unhealthy substance use screening and intervention in primary care
  • Patient-centered communication skills, including Motivational Interviewing and Behavioral Activation
  • Teamwork and team-based care

Support is provided in multiple formats, including on-site training and coaching, virtual training and coaching, and via PRHI’s web-based quality improvement portal, Tomorrow’s HealthCareTM. Our team is skilled at working collaboratively with staff at all levels of primary care organizations, from the frontline to the C-Suite. We work with all types of primary care practices, from rural solo-practitioner offices, to medium-sized practices, to large practice networks and Federally Qualified Health Centers.

Through our years of working with primary care practices we’ve learned that for training and coaching services to be successful in creating the capacity within the organization for sustainability and continuous improvement, learning solutions must be customized to the needs of the individual primary care practice. That’s why we begin all engagements with an assessment of an organization’s needs and current condition, and design interventions to achieve the organization's goals.

PRHI has developed a comprehensive, customizable curriculum that integrates EHR meaningful use standards with PCMH standards and incorporates practical, real-life examples of how to implement and optimize patient-centered workflows. The curriculum features examples of how the organization’s specific EHR can be used to support PCMH workflows, making it accessible to staff at all levels of the organization. The following outline highlights the PCMH/EHR optimization curriculum that may be customized for any practice:

 

Topic  Content 
 Introduction to the PCMH  
  • PCMH overview—what is it, why does it matter, and why should we turn our practices inside out to implement it?
  • Define participants’ PCMH training and support needs
  • Define the ideal and current condition (where are the practices now with PCMH, and where do they want to be? What are the strengths to support success and anticipated barriers?)
  • The PCMH framework—“Change Concepts” model
  • Overview of the NCQA recognition process
Practice Transformation Foundational Element: Quality Improvement Strategy  
  • Why do we need a quality improvement (QI) strategy to implement and sustain PCMH?
  • Approaches to QI—PDSA, Lean
  • Workflow redesign tools and techniques (problem solving, observation, process mapping)
  • Using data to drive improvement
Practice Transformation Foundational Element: Engaged Leadership  
  • The role of leaders in PCMH practice transformation
  • What does engaged leadership look like? Leadership behaviors of executive, middle, and frontline managers
Practice Transformation Foundational Element: Team-based care  
  • What is team-based care? How does it differ from “usual care?”
  • Maximizing the skills, talents and licensure of team members
  • Expanding roles
  • Redesigning workflow to support team-based care
NCQA PCMH Standard 1: Enhance Access and Continuity  
  • Empanelment—knowing our patient panels
  • Assessing access and continuity
  • Strategies for implementing same-day appointments and 24-hour access to the care team
  • Assessing and addressing the cultural and linguistic needs of our patients
NCQA PCMH Standard 2: Identify and Manage Patient Populations  
  • What is population management? How does it differ from traditional approaches to care?
  • The changing roles and responsibilities of providers and staff
  • Designing workflows for population management
  • Using the EHR to support population management
  • Leveraging the care team to complete comprehensive health assessments
  • Using data for population management
NCQA PCMH Standard 3: Plan and Manage Care  
  • Using the EHR to implement evidence-based guidelines
  • Identifying high-risk patients
  • Pre-visit planning (team huddles, proactive outreach)
  • Developing a care plan with patients and families
  • Using the EHR to document care plans
  • Implementing and tracking progress of care plans
  • Care management for high-risk patients
  • Workflows for medication reconciliation and management
NCQA PCMH Standard 4: Provide Self-Care Support and Community Resources  
  • Self-management support resources
  • Developing self-management goals with patients and families
  • Leveraging the EHR for self-management tools
  • Making connections with the community to support self-management
NCQA PCMH Standard 5: Track and Coordinate Care  
  • “Closing the loop” on tests and referrals
  • Workflow redesign to support referral/test tracking
  • Leveraging the EHR for referral/test tracking
  • Facilitating smooth transitions of care
NCQA PCMH Standard 6: Measure and Improve Performance  
  • Using data to drive change and monitor progress
  • Making sense of metrics
  • Designing productive QI team meetings
  • Incorporating patient/family feedback into improvement design
  • Setting improvement goals

 

Our Team

We believe that people make the difference in any professional relationship. Providing quality service depends on the team of professionals who work with client organizations. Our team brings a broad spectrum of relevant experience. Our enthusiasm and commitment ensures that clients receive responsive and innovative service as well as future-oriented advice. Our primary care training and coaching team includes:

 

Bruce Block, MD
Chief Learning and Medical Informatics Officer

Dr. Block is the Chief Learning and Medical Informatics Officer for the Pittsburgh Regional Health Initiative, supporting the implementation of electronic health records (EHRs) and data-intensive quality improvement methods in medical practice. He is responsible for the PA REACH West initiative to bring physician practices online with electronic health records and to help them achieve meaningful use. Covering a territory stretching from Erie to Greene County, PRHI's REACH initiative is serving over 860 providers in 305 practice sites. Dr. Block also serves as physician lead for the Safety Net Medical Home Project and for the COMPASS care initiative, implementing care management to improve the outcomes of persons with depression and chronic disease.

Dr. Block began practice as a family doctor in rural western Pennsylvania in 1972. In 1981, he joined the faculty of the Shadyside Family Medicine residency program. In 1985, he developed and implemented an EHR at the Shadyside Family Health Center practice. In 1998, he co-founded the Centers for Healthy Hearts and Souls, a non-profit health promotion organization in partnership with more than 40 African-American churches and community organizations. After 15 years as the medical director of the Shadyside Family Health Center, Dr. Block created the Shadyside Primary Care Institute where he developed quality improvement software for physicians, researched and published articles about practice improvement and community health, and serves as clinical Professor of Family Medicine and adjunct Professor of Biomedical Informatics at the University of Pittsburgh School of Medicine. Dr. Block earned his medical degree from Yale University.

 

Robert Ferguson
Program Manager

Mr. Ferguson is a program manager focusing on Partners in Integrated Care (PIC), an initiative funded by the Agency for Healthcare Research and Quality that aims to integrate physical and behavioral health in primary care practices using evidence-based models (IMPACT and SBIRT). In this role, he is responsible for PIC product development, federal reporting, and assisting a national steering committee with policy development and multi-state implementation and dissemination. He also serves as the site director for Care of Mental, Physical, and Substance Use Syndromes (COMPASS) in Pennsylvania, an initiative led by the Institute for Clinical Systems Improvement and funded by a Health Care Innovation Award from the Centers for Medicare & Medicaid Services. COMPASS also aims to integrate physical and behavioral health in primary care practices. Additionally, he provides support to the Pennsylvania Health Funders Collaborative (PHFC), a state-wide network of 31 health foundations. PHFC strives to improve the effectiveness of health funders' initiatives by collaborating, creating a unified voice among Pennsylvania health funders, and building knowledge of current developments and intersections in health philanthropy and health policy. Previously, Mr. Ferguson was a program associate for the Integrating Treatment in Primary Care demonstration project, which piloted a combined model of IMPACT and SBIRT. While a student at Northeastern University's Bouvé College of Health Sciences, he interned at the University of Pittsburgh's Center for Exercise and Health Fitness Research, at the Jewish Healthcare Foundation, and at the Massachusetts Executive Office of Health and Human Services. Mr. Ferguson earned his BS in Health Sciences from Northeastern University.

 

Contact Us

For more information about PRHI and our Learning Solutions for Primary Care, please contact:

Jennifer Condel, SCT(ASCP)MT
Manager of Lean Healthcare Strategy and Implementation
This email address is being protected from spambots. You need JavaScript enabled to view it.
412-594-2589