Home > Strengthening Primary Care and Care Coordination Models
Last Update: 9/20/2021

Strengthening Primary Care and Care Coordination Models

Develop the coordination of a regional approach that will Strengthen Primary Care and Care Coordination (SPC3) throughout the Great Lakes Bay Region. SPC3 will begin with the planning and design phases to enhance primary care team models that better coordinate clinical, behavioral, social, and economical services.
This intervention will allow our region to further:
  • Increase physical and behavioral health services that are available at local schools through primary care
  • Centralize referrals that address the social determinants of health through the deployment of community health workers
  • Bring together and leverage multiple community- based programs and stakeholders to create a single point of contact that ensures coordination of care across sectors
For More Information:

Strengthening Primary Care and Care Coordination Models Mini Dashboard

Compared to the MI Value ($1,181.0), MiHIA has a value of $1,019.1 which is lower and better. Average Total Cost Per Medicare Beneficiary With 0 Chronic Conditions
(Compared to MI State Value)
Compared to the prior value, MiHIA ($8,307.2) is greater and worse than the previously measured value ($7,734.4). Healthcare Expenditures Per Capita
(Compared to Prior Value)
Compared to MI Counties, MiHIA has a value of 69.4% which is in the best 50% of regions. Regions in the best 50% have a value higher than 67.4% while regions in the worst 25% have a value lower than 61.9%. Immunization Status of 19 to 35-Month-Old Children
(Compared to MI Counties)
Compared to the prior value, MiHIA ($8,096.3) is greater and worse than the previously measured value ($7,414.2). Medicaid Payments Per Capita
(Compared to Prior Value)
Compared to MI Counties, MiHIA has a value of 58 which is in the best 50% of regions. Regions in the best 50% have a value higher than 50 while regions in the worst 25% have a value lower than 32. Primary Care Provider Rate
(Compared to MI Counties)
 

Up to Date Progress

We believe that monitoring the progress of our interventions is a essential process that comes into play between setting and attaining a desired end. Continuous, up-to-date progress-tracking is the best way to ensure that the objectives are translated into action.

                             

        Implementation Stage                                Expansion Stage                                       Scaling Stage                                    Sustainability Stage

The progress-tracking graphic above is a handy visual aid designed for a "quick glance" update. The graphic color will update as we continue towards a path of successful completion of this intervention.
Key
  • Red: Signifies no work has been completed
  • Orange: Signifies a plan has been created to begin work on the intervention
  • Yellow: Signifies action has been created for the intervention
  • Light Green: Signifies action has begun towards executing all of the objectives and some strategies are completed
  • Dark Green: Signifies significant progress towards completion of all objectives 

Intervention Progress per Objective and Strategy

Learn more by exploring the objectives below

 

Objective 1: Identify and standup the formal planning committee

  • Strategy 1.1 - Recruit, convene and orient Planning Committee

    Responsible Party:
    Dr. Mark Kato via THRIVE
    Data:
    Action has begun towards executing this objective
    Target Completion Date:
    Fall 2021
    Progress Highlights and Significance:
    A multi-disciplinary committee comprised of providers, administrators, clinical staff, patients, and healthcare professionals will be paramount in identifying gaps and completing health system redesign projects in our current primary care ecosystem

  • Strategy 1.2 - Convene Planning Committee Meetings Every 3-4 Weeks

    Responsible Party:
    Dr. Mark Kato via THRIVE
    Data:
    Action has begun towards executing this objective
    Target Completion Date:
    Fall 2021
    Progress Highlights and Significance:
    A multi-disciplinary committee comprised of providers, administrators, clinical staff, patients, and healthcare professionals will be paramount in identifying gaps and completing health system redesign projects in our current primary care ecosystem

  • Strategy 1.3 - Transition to an Implementation Team

    Responsible Party:
    Dr. Mark Kato via THRIVE
    Data:
    Action has begun towards executing this objective
    Target Completion Date:
    Fall 2021
    Progress Highlights and Significance:
    A multi-disciplinary committee comprised of providers, administrators, clinical staff, patients, and healthcare professionals will be paramount in identifying gaps and completing health system redesign projects in our current primary care ecosystem

Objective 2 - Complete a Gap-Analysis of the Local Primary Care Ecosystem and Identify Opportunities to Strengthen Care Team Models and Improve Care Coordination

  • Strategy 2.1 - Complete a gap analysis of the local primary care ecosystem and identify opportunities to strengthen care team models and improve care coordination

    Responsible Party:
    THRIVE Primary Care Team
    Data:
    Action has begun towards executing this objective
    Target Completion Date:
    Fall 2022
    Progress Highlights and Significance:
    A robust analysis must completed to highlight areas of opportunity in our current ecosystem. There are numerous best practice guidelines to implement high quality primary care and the committee must understand what opportunities exist within the region.

  • Strategy 2.2 - Incorporate Businesses and Business Leaders to Help Refine the Model of Primary Care and Address the Needs of their Employees

    Responsible Party:
    THRIVE Primary Care Team
    Data:
    Action has begun towards executing this objective
    Target Completion Date:
    Fall 2022
    Progress Highlights and Significance:
    A robust analysis must completed to highlight areas of opportunity in our current ecosystem. There are numerous best practice guidelines to implement high quality primary care and the committee must understand what opportunities exist within the region.

  • Strategy 2.3 - Incorporate and Empower Providers to Innovate and Round-Out the Care Team to Enhance Primary Care Where Gaps Exist in Their Service Areas

    Responsible Party:
    THRIVE Primary Care Team
    Data:
    Action has begun towards executing this objective
    Target Completion Date:
    Fall 2022
    Progress Highlights and Significance:
    A robust analysis must completed to highlight areas of opportunity in our current ecosystem. There are numerous best practice guidelines to implement high quality primary care and the committee must understand what opportunities exist within the region.

Objective 3: Develop a workplan to be implemented that addresses problems, gaps and opportunities to Strengthen Primary Care & Care Coordination with Primary Care at the Center of the model


2022

  • Strategy 3.1 - Charter a sub-committee to develop an implementation workplan

    Responsible Party:
    THRIVE Primary Care Team
    Data:
    Action has begun towards executing this objective
    Target Completion Date:
    Summer 2022
    Progress Highlights and Significance:
    A coordinated action plan must be developed that addresses the gaps in our primary care ecosystem. It is paramount that repeatable processes are defined so that health systems and providers in our region have a clearly defined path to success

  • Strategy 3.2 - Engage businesses to offer comprehensive benefits for multi-disciplinary services

    Responsible Party:
    THRIVE Primary Care Team
    Data:
    Action has begun towards executing this objective
    Target Completion Date:
    Summer 2022
    Progress Highlights and Significance:
    A coordinated action plan must be developed that addresses the gaps in our primary care ecosystem. It is paramount that repeatable processes are defined so that health systems and providers in our region have a clearly defined path to success

  • Strategy 3.3 - Incorporate religious and other community agencies to promote primary care

    Responsible Party:
    THRIVE Primary Care Team
    Data:
    Action has begun towards executing this objective
    Target Completion Date:
    Summer 2022
    Progress Highlights and Significance:
    A coordinated action plan must be developed that addresses the gaps in our primary care ecosystem. It is paramount that repeatable processes are defined so that health systems and providers in our region have a clearly defined path to success

  • Strategy 3.4 - Engage community & government providers to partner, provide, and subsidize services

    Responsible Party:
    THRIVE Primary Care Team
    Data:
    Action has begun towards executing this objective
    Target Completion Date:
    Summer 2022
    Progress Highlights and Significance:
    A coordinated action plan must be developed that addresses the gaps in our primary care ecosystem. It is paramount that repeatable processes are defined so that health systems and providers in our region have a clearly defined path to success

Objective 4: Objective 4: Develop a sustainability plan where Medicaid, Medicare, commercial insurers, and self-insured employers—using a fee-for-service (FFS) payment model for primary care should shift primary care payment toward hybrid (part FFS, part capitated) models, making them the default method for paying for primary care teams over time.


2022

  • Strategy 4.1 - Recruit Payors who represent local organizations to help develop and implement a hybrid payment model

    Responsible Party: 
    THRIVE Primary Care Team
    Data:
    Action has begun towards executing this objective
    Target Completion Date:
    Fall 2022
    Progress Highlights and Significance:
    High quality primary care will be dependent upon alternative payment models in the future. The current environment of fee for service does not support the health of the whole individual. Partnering with payors and businesses to support high quality primary care will be necessary in creating a sustainable primary care ecosystem.

  • Strategy 4.2 - Assemble a compilation of coding and billing resources

    Responsible Party: 
    THRIVE Primary Care Team
    Data:
    Action has begun towards executing this objective
    Target Completion Date:
    Spring 2022
    Progress Highlights and Significance:
    High quality primary care will be dependent upon alternative payment models in the future. The current environment of fee for service does not support the health of the whole individual. Partnering with payors and businesses to support high quality primary care will be necessary in creating a sustainable primary care ecosystem.

Objective 5: Develop reporting that will be utilized to design appropriate primary care teams to best serve the population and measure the quality and financial impacts of multi-disciplinary care


2022

  • Strategy 5.1 - Create a reproducible algorithm to identify the appropriate composition of multi-disciplinary primary care teams.

    Responsible Party:
    THRIVE Primary Care Team
    Data:
    Action has begun towards executing this objective
    Target Completion Date:
    Spring 2022
    Progress Highlights and Significance:
    Health systems and providers need to be able to address the needs of their population. The development of reports used to identify the appropriate care team members are vital to ensure the needs of the community are met and are self sustainable.

  • Strategy 5.2 - Create reproducible reports and/or dashboards to monitor the effectiveness both in quality and financially

    Responsible Party:
    THRIVE Primary Care Team
    Data:
    Action has begun towards executing this objective
    Target Completion Date:
    Spring 2022
    Progress Highlights and Significance:
    Health systems and providers need to be able to address the needs of their population. The development of reports used to identify the appropriate care team members are vital to ensure the needs of the community are met and are self sustainable.

Michigan Health Improvement Alliance