Visit Planning Care Team Transformation to Achieve the Quadruple Aim

The Community Health Care Association of New York State (CHCANYS) piloted a patient-centered care team transformation project with 11 Federally Qualified Health Centers over a two-year period with funding from the CDC and the New York State Department of Health. Through implementation of a pre-visit planning tool, health centers streamlined care delivery processes and redistributed patient care responsibilities across the care team. Participating health centers engaged leadership to make key decisions related to technical and clinical workflows, configuration of the pre-visit planning report, and redefinition of staff roles and responsibilities. Medical assistant and provider teamlets utilized the tool during daily huddles to identify gaps in required preventative and chronic disease care, and then addressed these needs during scheduled patient visits. A key focus of the project was ensuring data accuracy of the report, and successful implementation of data-driven huddling to other care teams. Following the three-month pilot, each health center demonstrated improved patient outcomes (some by up to 30%) and staff satisfaction. Common challenges and successes will be presented, followed by the specific experience of Settlement Health, a participating CHC in New York City.

• - Describe the change management phases employed for successful care team transformation.
• - Illustrate ways care team transformation can help practices achieve the goals of the Triple Aim.
• - Articulate benefits implementing visit planning in a health center.