Putting Advanced Primary Care Into Practice

CQC’s Advanced Primary Care attributes define the core characteristics of high-quality, person-centered primary care. As the delivery system evolves toward more whole-person, integrated care, organizations also need practical ways to translate those attributes into everyday care delivery.

The examples below illustrate how practices can operationalize each attribute with greater integration of physical health, behavioral health and social needs. They are not intended as a checklist or a single model for implementation. Organizations can adapt these approaches based on their patient populations, care teams, partnerships and available resources.

Together with CQC’s Advanced Primary Care attributes and measure set, these operational examples provide a shared foundation for defining, implementing and evaluating high-quality primary care.

Person- and family-centered

• Care pathways and process flows reflect how patients access support for physical health, behavioral health and social health needs
• Shared decision-making processes are established for physical health and behavioral health needs
• Care teams tailor communication to meet language needs and cultural context, including addressing perceived stigma, cultural norms and barriers and preferred treatments

Relationship-based

• Patients have the option to receive support from a consistent care team that knows their physical, behavioral and social health history, regardless of whether services are provided on-site or by virtual-only providers

Accessible

• Practices work toward same-day access for behavioral health services; the spectrum of integration could begin with a protocol for a same-day warm hand-off to virtual or co-located behavioral health services and move toward same-day care over time
• Warm hand-offs are provided to behavioral health support in a timely manner

Comprehensive

• An array of integrated and evidence-based services for mental health and substance use disorder (SUD) care is available from the team or via referral to virtual or community-based providers. Services may be available from co-located or virtual providers (e.g., identification and treatment of mental health conditions such as depression and anxiety, screening for SUD, providing medications for addiction treatment (MAT) and offering SUD support groups)
• Offer support for behavior changes that impact chronic illness (e.g., addressing nutrition and exercise for patients with diabetes or obesity)

Team-based

• Care pathways and process flows are designed around an integrated team and ensure that behavioral health symptoms associated with chronic physical health diagnoses are addressed
• Behavioral health providers participate in practice activities (e.g., care team meetings)
• Daily huddles include the integrated care team and address behavioral health issues (e.g., flagging patients who might benefit from a warm hand-off to behavioral health and reviewing patients with complex conditions to confirm physical, behavioral and social health needs)

Integrated

• Care plans span physical health, behavioral health, and social health needs
• There are established mechanisms to share care plans and for providers to work together to identify and address behavioral health and social risk factors
• EHRs are optimized for integrated care teams, including the following mechanisms where feasible:
  (a) PCPs and behavioral health providers document in the same record;
  (b) modules that offer progress tracking and task assignments are enabled;
  (c) role-based permissions are tailored so sensitive behavioral health information is only available to relevant team members;
  (d) secure messaging is enabled for teams to message one another about time-sensitive issues; and
  (e) a patient-centered consent process offers patients the ability to indicate which parts of the record can be shared.

Coordinated

• Referral relationships are established with key community-based providers that address behavioral health and social risk factors
• Relationships may be formalized (e.g., a memorandum of understanding to align referral expectations across each provider)
• Practices have implemented processes to improve efficiency, patient experience and provider experience (e.g., EHR smart phrases for referrals, lists of vetted resources with capacity and/or care coordination support to help with patient navigation)
• Closed-loop referrals ensure that integrated care teams know when patients have accessed external care provided by referral

Equitable

• Behavioral health support is delivered by providers who are culturally responsive and language concordant
• Practices monitor data to address disparities in screening, diagnosis and follow-up for behavioral health conditions