Primary Care Transformation Guide

The goal of this guide is to provide learning resources for clinics desiring to pursue the six Transforming Clinical Practice Initiative aims, transform their practice, deliver value-based care, and contract for value-based payment.

Each page provides learning resources for one of the aims/outcomes, with specific information provided to advance the clinic through the five phases to practice transformation.

Kathy Patterson
EMR Manager
Child and Adolescent Clinic

Phyllis M. Cavens, MD, FAAP
Lead P-TCPI Primary Care Team
Child and Adolescent Clinic

Decrease ED Visits

TCPI Aim: Reduce Emergency Department visits by 5% from baseline.

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Increase Well Child Visits

TCPI Aim: Increase the well child visit rate for children ages 3-6 years old (HEDIS measure W34) by 10%.

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Increase Asthma Care

TCPI Aim: Increase asthma medication management (long term controller medication) for patients age 5 and older with persistent asthma 10% from baseline. CMS 126

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Increase Immunization Rate

TCPI Aim: Increase Combo 10 immunization rate by 10% from baseline. CMS 117

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Increase BH Integration

TCPI Aim: Integrate behavioral health into primary care; integrate primary care into behavioral health.

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Decrease Advanced Imaging

TCPI Aim: Decrease unnecessary imaging (CT, MRI) to generate cost savings.

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