Sustainability Services

When a practice is in the “succeed” phase of Patient-Centered Medical Home Recognition, it is important they do just that – succeed in the activities they have diligently worked on during the transformation phase. All too often, after the initial recognition is achieved, practices slide back to their old ways of doing things and the efforts they put into achieving recognition are not sustained.

Our Sustainability Service is conducted through a series of touch points of communication and work throughout the year. Each consists of about eight hours of advising and is done remotely. We will review reporting and quality improvement efforts, and we’ll perform mini-audits geared to ensure that your practice is maintaining the workflows, roles, responsibilities and processes established during the transformation phase.

As with all of our engagements, our Sustainability Service is fully customizable. Your practice can add to the base service to meet your unique needs. For example, medical groups with multiple locations may want more hours per quarter to work through strategies, reporting and individual practice level support, or your practice may be interested in annual in-person training for staff.

Examples of additional services include:

Q-PASS Navigation

Free up your staff from the administrative activities associated with Q-PASS.

Practice Retreat Facilitation

Ensure your staff and clinicians are up-to-date on the fast-paced changes in healthcare reform and advancements in the medical home or medical neighborhood. Our transformation advisors will develop content and facilitate your practice retreat or meetings either remotely or in-person.

Quality Improvement/Performance Improvement Focus

This is especially beneficial for practices that do not have a resource dedicated to quality improvement. Our advisors go beyond the work supplied in the base service by creating QI strategies, providing data analysis assistance, establishing Plan-Do-Study-Act cycles and engaging staff in the QI process.

Value-based Payment Focus

Sustainability is a core criterion for NYS PCMH. During the sustainability phase, we help ensure the base requirements are continued. If your practice is looking to analyze its performance in sustainability arrangements or strategies to move to the next level of risk sharing, additional hours can be applied to support your goals.

Care Coordination Focus

Is your practice squeaking by with the bare minimum for care coordination, and you want to up your game? Are you in a risk-sharing arrangement and want to improve care coordination along the continuum by engaging more with specialists and community-based organizations? PAS can help you achieve this.

Social Determinants of Health Focus

An SDH focus can help bend the cost curve and improve patient outcomes. Many practices do not have the staff to support education on SDH or the data analytic expertise needed to incorporate a strong SDH program into their operations. We can support your practice with SDH education, identification and establishing relationships with community-based organizations and other medical neighborhood members so you can collaborate and improve patient care outside of your practice walls.