Engaged leadership

1. 10 Building Blocks of High-Performing Primary CareThe Share-the-CareTM Model Template of the future 8 9 Prompt access to care Coordination of care 5 6 7 Patient-team partnership Population management Continuity of care 1 2 3 4 Engaged leadership Data-driven improvement Empanelment Team-based care

2. SF Partnership for Population-focused care SFCCC, CEPC, SFDPH, SFHP Complex Care Management Team: RN, SW, Health Coach Level 3: 5% Complex healthcare needs Level 2: 80% Multiple chronic conditions: diabetes, HTN, COPD Primary Care Team: PCP, continuity NP, RN, MA, Clerk, Behaviorist Primary Care Team: PCP, continuity NP, RN, MA, Clerk, Behaviorist Level 1: 15% Uncomplicated chronic disease or risk factors: obesity, pre-diabetes

3. GMC Care Management Team Roles

5. 2012 Colorectal Cancer Outreach Project • Joint effort: SFDPH-PC, CEPC , SFHP • Training: colon CA, registry, outreach skills. Outreach Work - off site, early evening. Mass mail out, phone banks • CEPC: In Time training on registry use, scripts + role play talking to patients, coaching during phone banks • 10 clinics, 35 staff • 4900postcards mailed (4 languages), 6 phone bank sessions: 2400 calls, 1200 FIT tests done in outreach group • Repeated in Sept 2012 • Screening rate 10 participating clinics up 19% over baseline from 02/2012 to 11/2012 (at 54% 11/2012) Slide Courtesy of Lisa Golden, M.D.

6. 10 Building Blocks of High-Performing Primary CareThe Share-the-CareTM Model Template of the future 8 9 Prompt access to care Coordination of care 5 6 7 Patient-team partnership Population management Continuity of care 1 2 3 4 Engaged leadership Data-driven improvement Empanelment Team-based care