Care Coordination Across the Medical Neighborhood

Welcome to the Care Coordination Across the Medical Neighborhood module, an ABFM-approved Performance Improvement (PI) activity eligible for PI credits toward Family Medicine Certification Requirements. This module will assist you in identifying and implementing key concepts related to coordinating patient care with other providers.

As you complete this module, you will receive hands-on practice in evaluating care measure outcomes; identifying measures for improvement; and devising a method, or intervention, to improve care through better coordination with your patients’ other healthcare providers. The “10 Building Blocks of High Performing Care” are described and integrated into the work required to complete this module.

As change and success are more readily accomplished as a team, you are encouraged to involve your staff in determining what kind of intervention would best benefit your patients and practice and in developing the plan for implementing the intervention.

If you wish to receive credit from ABFM, the following criteria must be met.

• As of July 24, 2023, all new submissions must be completed within a 12-month window (not calendar year). This does not apply to those who submitted pre-intervention plans prior to this date.
• You will need to fill out a pre-intervention plan, implement your plan for 7 days, submit data at least 7 days later, and then complete and submit a post-intervention plan.

Unless you fulfill these obligations, you will only receive a certificate of completion at the end of this module.

Learning Objectives

Upon completion of this module, the learner should be able to:

1. Perform a pre-intervention and post-intervention audit of clinical data and recognize data as a tool for monitoring for successful change.
2. Identify at least one evidence-based quality indicator related to care coordination across the medical neighborhood.
3. Develop and implement a quality improvement initiative utilizing SMART (specific, measurable, attainable, realistic, timely) goals and a workflow map.
4. Apply knowledge gained from a post-intervention data audit to improve the intervention via a second Plan, Do, Study, Act (PDSA) cycle.

The project described was supported by Funding Opportunity Number CMS-1L1-15-002 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies. The American Board of Family Medicine, Inc. owns and operates The PRIME Registry™