Transforming Clinical Practice & Population Health
A mix of social, environmental occupational and economic factors collectively labelled the social determinants of health (SDH) have a greater combined influence on the morbidity and mortality of our patients than the services we deliver in traditional medical care.
Transforming Clinical Practice & Population Health
A mix of social, environmental occupational and economic factors collectively labelled the social determinants of health (SDH) have a greater combined influence on the morbidity and mortality of our patients than the services we deliver in traditional medical care.
Events & Convenings
Workshop
Designing Future State to Account for Social Risk in CMS Payments
January 11, 2021
This invitation only workshop is a one, full-day brainstorming event to design a future state CMS payment system that incorporates social risk in a sustainable, equitable way. This convening of CMS, ASPE, safety net health plan, clinician, state, and patient stakeholders provides the unique opportunity to collaboratively design potential new approaches to risk adjustment for the Medicare and Medicaid programs.
PHATE brings together community, social determinant and clinical data to help transform the way practices identify risk and address population health. PHATE allows users to attach geography to their patient data, to better associate them with the community in which they live.
When used within the PRIME Registry, PHATE uses EHR and Community Data to:
- Map physician or clinic service area
- Show clusters of disease
- Show clusters of poor outcomes
- Pull in social determinant data (poverty, less than high school ed., single parent household, unemployment etc.)
- Create a Community Vital Sign for every patient
- Display community resources for patients and practice
The resulting reports and information help clinicians and practices better understand the characteristics of patient risks, illuminating local resources and opportunities for assistance, intervention and improvement.
Helping Practices Stay Viable
PRIME Registry was established by the American Board of Family Medicine (ABFM) in 2016. The ABFMis the only certifying board to run a Qualified Clinical Data Registry and did so because there was not already a resource to help small practices stay viable as reporting requirements ramped up.
A Research and Development Platform
PRIME has also become an important platform for developing and testing high-value primary care measures and getting them endorsed by CMS for MIPS reporting. It is increasingly an important research platform enabling primary care to tell its story about the epidemiology, quality, and effectiveness of front-line practices.
The PRIME Mission
With the PRIME registry, we aim to relieve burden, improve quality assessment/improvement, prioritize measures that matter, and attract resources to primary care sufficient to support comprehensive, relationship-rich care.
Recommended Reading
Download the pdf
(1.2 MB)
Factors Mediating Burnout in Medical Residents and Interventions to Address Them
An Annotated Bibliography
The PubMed database was searched for relevant literature using specific search terms including “burnout”, “residency” and “resilience”. Papers not relating to residency in the United States, in languages other than English and prior to 20 years ago were omitted from the search results. The search results were further narrowed to meet criteria relevant to the topic and the target audience. While the majority of papers related specifically to residents, several pertaining to recent graduates of residency programs or practicing physicians were included for completeness and relevance. These have been marked with an asterisk. Systematic reviews and meta-analyses were prioritized but relevant clinical trials and case studies were included as well.
How Comprehensive Medication Management Contributes to Foundational Elements of Primary Care
Kylee A. Funk, Lindsay A. Sorge, Andrew W. Bazemore, Todd D. Sorensen, Mary T. Roth McClurg, Jennifer K. Carrol
Pharmacists are more often being recognized as a critical component of the primary care team. Previous literature has not clearly made the connection to how pharmacists and comprehensive medication management (CMM) contribute to recognized foundational elements of primary care. In this reflection, we examine how the delivery of CMM both supports and aligns with Starfield’s 4 Cs of Primary Care. We illustrate how the delivery of CMM supports first contact through increased provider access, continuity through empanelment, comprehensiveness by addressing unmet medication needs, and coordination through collaborating with the primary care team and broader team. The provision of CMM addresses critical unmet medication-related needs in primary care and is aligned with the foundational elements of primary care.