Commonwealth Fund Case Study Points to 'Continuous Innovation' at Group Health C...(risk assessment linked to EHR identifies...),Health

Care Coordination and Transitions & System Accountability (two attributes)

• Implementing patient-centered medical-home model of primary care to promote proactive care coordination and patient engagement.
• Complex case management for sickest/costliest patients to coach patients and reduce hospitalizations. Palliative care program with physician home visits for homebound patients. Anticoagulant management service has reduced adverse drug events by 26 percent.

Peer Review and Teamwork for High-Value Care

• A mission-driven, values-based organizational culture brings people together to achieve higher performance.
• Clinical dashboards communicate comparative physician performance. Performance-based pay rewards achievement on quality, patient satisfaction, productivity, and engagement.

Continuous Innovation

• Innovative use of information technology to promote patient-centered and coordinated team care, e.g., home blood-pressure monitoring using the online patient portal, supplemented by online pharmacist-led care management.
• Content of care program aims to improve quality by reducing unwarranted variations in care and by involving patients in shared decision-making so that care reflects their preferences.

Easy Access to Appropriate Care

• Same-day primary care appointments for urgent needs. After-hours urgent care and telephonic nurse advice tied to EHR. Direct access to specialists.
• Group visits enhance educational opportunities and build soci
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