QualityImpact PTN Resource Library
YOUR GO-TO SOURCE FOR PRACTICE TRANSFORMATION TOOLS, PUBLISHED LITERATURE, AND resources for alternative payment model readiness
Resource List
preparing for apm participation
Results Relating to Aims
Understand the requirements and options for participating in MIPS (guide here) and various APMs (guide here)
Gaining the support of internal staff is critical to APM success (one-pager here) and it is imperative to go into external negotiations prepared (one-pager here)
Results Related to Aims
Results Relating to Aims
HRSA Performance Management and Measurement – A U.S. Department of Health resource for organization performance
TCPi Quality Measures – TCPi Benchmarks for measuring quality to meet your organization's goals
Quality and Resource Use Reports (QRUR)
CMS Guide for Obtaining a New EIDM Account – The role of physician quality and value programs
Guide to Access QRURs – Accessing the 2015 Annual QRURs and Tables according to CMS
What you Need to Know About QRURs – Family Practice Medicine explains how your QRUR affects how you will get paid in the future
Understanding QRURs – How to interpret your annual QRUR report according to CMS
CMS Guide for Obtaining Physician Quality and Value Program Role for Existing EIDM Accounts – Using your EIDM account to access the physician quality and value programs in CMS Enterprise Portal
Patient and Family-centered Care Design
Patient and Family Engagement
Engaging Patients in their Health and Healthcare – A Safety Net Medical Home Initiative’s implementation guide
Informing And Involving Patients To Improve The Quality Of Medical Decisions – A Health Affairs Journal article
Tools to Enhance Patient Engagement – Presentations by Insignia Health, PeaceHealth Medical Group, and MultiCare Health System
Shared Decision Making Toolkit AHRQ:
Be More Involved in Your Healthcare (Tips for Patients) – Pamphlet for patients to make the most out of their health care
Health Literacy and Shared Decision Making Guide for Providers – Communicating with your patients in making shared decisions concerning their health
Shared Decision Making Guide with Sample Conversation Starters – Five step process to ensure effective shared decision with patients
Shared Decision Making Brief for Administrators and Practice Leaders – Using shared decision making to establish patient-centered care
Team Based Relationships
Access & Scheduling Policies & Procedures – An ACP policy and procedures document
High Value Care Coordination Toolkit – ACP’s recommendations on care coordination
The Ideal Patient Visit Toolkit (Coleman) – Ideas to create the ideal patient visit at your practice
Team Roles
Implementing Care Teams (AHRQ) – Practice handbook for implementing care teams
Implementing Team Based Care (AMA Step):
Core Concepts for Team Based Care – Ideas to create team-based care professionals at your practice by BellinHealth
Core Principles for Team Based Care – Fundamental behaviors for team-based care by BellinHealth
Implementing Team-Based Care – Slide show describing how to utilize tools to implement team-based care into your practice
Pre-Visit Questionnaire – Printable questionnaire for patients to fill out before rooming
Process Map Toolkit – Process flows depicting how to manage your patient's time while in your practice
Rooming Checklist – Printable checklist to create process efficiency before the patient sees the physician
Visit Planner Checklist – Printable patient visit checklist to be completed during the visit
Discharge Checklist – Printable checklist to run through with your patient after the appointment
Team Based Care (FPM) – Maximize efficiency and minimize waste by delegating tasks
Care Team Roles (QI and PCP) – Primary care team members and examples of their roles
Team Huddles
AMA Team Huddle Resources:
Team Huddles – Pamphlet detailing how to increase productivity and morale through team huddles
Team Huddle Checklist – Printable checklist to complete during team huddles by the AMA
Huddle Evaluation – Printable form to assess team huddles from the AMA
Visit Preparation Checklist – Printable checklist to be completed before a patient's appointment
Cycle Time
AAFP Tools to Improve Office Efficiency – Use business techniques to reduce waste within you practice
Patient Cycle Time Process – How to measure cycle time and tips to reduce cycle time
Cycle Time Tool Example – Example forms to track patient cycle time
Patient Visit and Cycle Time Tracking Toolkit (Coleman) – How to track patient visits effectively
Population Management
A Population Health Guide for Primary Care Models – A Care Continuum Alliance guide to incorporating population health strategies and patient-centered care into your practice
Addressing the Social Determinants of Health Within the Patient-Centered Medical Home – An AMA article on how a patient's social context impacts their health
It is Time to Start Practicing Population Based Healthcare (FPM) – Four step system to optimize care for patients with a certain condition
Population Heath Transition (Mayo) – Shifting toward enterprise-wide health management
Understanding your Population:
Understanding Your Patient Populations – The importance of knowing your population's metrics
Assigning Primary Care Providers (Empanelment)
Empanelment Implementation Guide – How to establish a patient-provider relationship
Practice as a Community Partner
CDC Community Health Improvement Navigator – A CDC website to support health systems and other community health stakeholders
Clinical-Community Relationships Measures Atlas – An AHRQ publication explaining how to collaborate with community-based organizations to deliver preventative services
County Health Action Center – County Health Ranking’s interactive guide on how to create and support a healthy community
M.A.P (Measure, Act, Partner) – AMA and CDC guide to help prevent type 2 diabetes
Coordinated Care Delivery
Coordinating Care in the Medical Neighborhood: Critical Components and Available Mechanisms – An AHRQ paper explaining the medical neighborhood and how to make it cohesive
Integrating Comprehensive Medication Management to Optimize Patient Outcomes Resource Guide – A Patient-Centered Primary Care Collaborative guide to provide coordinated, individualized care for patients
Optimizing Referrals and Consults With a Standardized Process – An AAFP Article for successful referrals and communication between you, your patient, and your consultant
Organized, Evidence-Based Care
About Choosing Wisely – An initiative by the ABIM Foundation to reduce unnecessary tests
Child/Adolescent Diagnostic Assessment – Minnesota Department of Human Service’s pre-visit pediatric mental health information sheet
LOCUS Recording Form – Minnesota Department of Human Service’s form to determine resource intensity necessary for mental health services
Enhanced Access
Clinical No-Show Rates: Is Technology a Contributor? - A Divurgent publication on how technology may be impacting the no-show rate and how to lower your no-show rate
Improving Health Care Access: Finding Solutions in a Time of Crisis – A NPCC publication intended to inform stakeholders how to impliment community-based collaboratives to better the populations health
Information for Healthcare Providers Who Want to Offer Group Visits to Their Patients – A Strategies for Chronic Care guide to group visits for patients with diabetes
Continuous, Data-Driven Quality Improvement
Engaged and Committed Leadership
Developing Effective Physician Leaders: An Imperative for Health System Change – An ACHP article on how change in policy can lead to more effective physicians
Strategies for Guiding PCMH Transformation from Within - A Safety Net Medical Home Initiative’s implementation guide to transform practices through visionary leaders
The Role of the Champion in Primary Care Change Efforts – An NIH research article on how change champions are essential in transforming care
Quality Improvement Strategy
Preparing Your Practice for Change – AMA Steps Forwards’ guide to achieve practice quality transformation
Quality Improvement in Primary Care: External Supports for Practices – An AHRQ publication on how external support can be utilized help with quality improvement
Transparent Measurement and Monitoring
Concise Practice Improvement Manual – Guide to collect and monitor quality data by Mark Cheren, EdD
Primary Health Care Patient Experience Survey – A Putting Patients First Toolkit on how to capture patient feedback
Optimal Use of HIT
Clinical Decision Support Systems: State of the Art - An AHRQ publication on how supplemental person-specific information can help lead to more informed decisions involving one's care
Using Health Information Technology to Support Quality Improvement in Primary Care - An AHRQ publication on methods to include IT to help improve care quality
Sustainable Business Solutions
Strategic Use of Practice Revenue
Elevating Physician Practice Performance – A Prism Healthcare Partners eBook to offer strategies on how to improve practice performance and reduce burnout
Integrating Chronic Care and Business Strategies in the Safety Net Toolkit – An AHRQ toolkit on Chronic Care Management to provide tools to help physicians deal with chronically ill patients
Primary Care Strategic Plan Template – The Advisory Board Company’s template for developing a comprehensive strategic plan
Revenue Cycle Management in Medical Practice - AMA Steps Forwards’ guide to automate revenue cycle processes
Workforce Vitality and Joy in Work
7 Ways to Hire Medical Staff for Keeps – Presentation with staff hiring tips
Concept Series Paper on Disease Management – AMCP paper on how to efficiently treat chronic diseases while lowering health care costs
Constructing Disease Management Programs – A Managed Care Magazine article on how to create a disease management program
Pay that Motivates Your Medical Practice Staff – An American Medical News article on the importance of how you pay medical staff
Six Keys to Motivating Medical Practice Staff – A Physicians Practice article explaining strategies to create a practice with motivated employees
Strategies for Value-Based Physician Compensation – A MGMA publication on how to maximize your practice during the transition to value-based compensation
Capability to Analyze and Document Value
Healthcare Finance 101 – Massachusetts General’s presentation on key financial concepts relevant to healthcare providers
Operational Efficiency
JIT in Healthcare: An Integrated Approach – An International Journal of Advances in Management and Economics research article on how to utilize JIT strategies can be applied to lower costs and increase quality in service industries
Recommended CLinical Resources
Cardiovascular Treatment & Management Protocol
A1c Management Protocol – Treatment protocol flow chart for Type II Diabetes (A1c < 7.5)
Hypertension Treatment Protocol – Evaluation, medication management, and recommended therapies
LDL Cholesterol Treatment Protocol – Diagnosis, medication management, and intensity-based therapies
Secondary Prevention of Coronary Artery Disease & Atherosclerotic Diseases – Protocol for risk reduction therapies
Primary Care Protocol for Congestive Heart Failure Reduced Ejection Fraction
Primary Care & Precision Medicine - Bringing it All Together Case Study
Pulmonary Clinical Protocol
Gastrointestinal / Cancer Screening
The Wellness Network - Heartcare Channel Resources
Educational Awareness Resources
Video Training Presentation – Provider and staff training for how to integrate videos into patient's workflow
HeartConnections Table Tents – Informational desk display announcing patient videos
HeartConnections Program Posters – Informational wall display announcing patient videos
HeartCare Program Library and Checklist – Comprehensive list of all available video content
Quality Payment Program Toolkit
Merit-Based Incentive Payment System (MIPS)
CMS Exclusion Notification Letter - Sample version of CMS notification sent to all practices excluded from the MIPS program in 2017
CMS Participation Notification Letter - Sample version of CMS notice sent to all practices who are currently subject to the MIPS program
MIPS Reimbursement Calculator - Use this tool to estimate points earned for each performance category and calculate your total score
MIPS Quick Start Guide - Timeline and simplified steps that your practice can follow to ensure successful participation
Quality Insights 2017 MIPS Worksheet - Record selected measures and track progress throughout the year
2017 CMS-Approved Qualified Clinical Data Registries (QCDRs) Vendor List
2017 Quality Performance Category
Quality Measure List - Complete list of reporting numbers, measure descriptions, submission methods and specifications
Quality Measure Benchmarks Overview - Introduction to the 2017 MIPS quality benchmarks and provider assessment
MIPS Benchmark Results - Comprehensive table of all 2017 quality benchmarks that will used to determine MIPS measure scores
NCQA Patient-Centered Medical Home Recognition Program
Program Requirements - Download the standards and guidelines document to learn the newly released concepts and criteria
Recognition Process - See the steps you need to take to get recognized
Toolkit: Getting Started - Learn more about NCQA recognition and what tools are available to assist with transformation
Am I Eligible & Ready? - Determine your eligibility and readiness for NCQA PCMH Recognition
Quality Performance Assessment Support System (Q-PASS) - Visit to the Q-PASS online portal to manage your recognition process
Behavioral Health and Substance abuse Disorders
QualityImpact recommends following the CDC's Recommendations for Determining when to initiate or continue opioids for chronic pain. Below is a summary and suggested resources to support your implementation. View CDC guidelines here.
Determining when to Initiate or Continue Opioids
1. Non-opioid pharmacologic or non-pharmacologic therapy
Encourage communication within practice about opioid prevention and management, however communication approach is left up to practice
2. Establish and measure goals for pain and function
Recommend using PEG pain screening tool
Assessing Pain and Interference (PEG) - Assessing pain based on average pain, enjoyment of life and general activity
3. Discussing benefits and risks & Patient contracts
Recommend using Patient-Provider Controlled Substance Education Agreement
Opioid Selection, Dosage, Duration, Follow-up and Discontinuation
4. Use Immediate-release opioids when starting therapy for chonic pain instead of (ER/LA)
5. Start low (less than 50MME/day) and go slow (avoid increasing to greater than 90MME/day)
Follow state guidelines
6. Acute pain, prescribe no more than needed and do not prescibe ER/LA opioids for acute pain
Follow state guidelines, with special consideration for using them for shortest duration since there is clear evidence that prescription duration has direct impact on long term outcomes (i.e. abuse)
View article on long term impacts
7. Follow-up and re-evaluate risk of harm; reduce dose or taper and discontinue if needed
Utilize the PEG tool to evaluate benefit, harms at every visit
Current Opioid Misuse Measure (COMM) - Patient self-assessment who are on opioids for chronic pain
Assessing Risk and Addressing Harms of Opioid Use
8. Evaluate risk factors for opioid-related harms
Provide naloxone as co-prescription with every opioid and use Opioid Risk Tool (ORT) prior to starting patients on any chronic opioid treatment
Opioid Risk Tool - Self-screening tool to determine potential risk for opioid abuse
Naloxone - Provide a co-prescription for every opioid prescription
Osteopathic Manipulative Treatment (OMT) - Provide options for pain management without the use of opioids
9. Check PDMP for high dosages and prescriptions from other providers
Follow state PDMP requirements
10. Use urine drug testing to identify prescribed substances and undisclosed use
Recommends use of UDS, included in patient education agreement and define frequency by clinic - for more information on urine drug screening, see what our advisers recommend here.
11. Avoid concurrent benzodiazepine and opioid prescribing
Limit co-prescribing unless provider deems it appropriate and documents the medical reason(s)
12. Arrange treatment for opioid use disorder if needed
Offer MAT in conjunction with CBT and other behavioral therapies in PCP setting, or arrange for evidence-based treatment in the community
Getting started guides
QualityImpact has compiled best practices and recommendations in a succinct manner for a range of topics.
Patient Management
Practice Operations