TA Domains

Includes strategies for value-based payment

• Designing global capitation billing and revenue models
• Practice/site-level support for developing risk-based financial and data infrastructure
• Aligning provider incentives with alternative payment methodologies

Includes ACO/CP integration, care coordination and care team development, and the integration of substance use disorder (SUD) services and long term services and supports (LTSS)

• Developing and implementing shared workflows and performance metrics
• Implementing team-based care
• Improving communication between ACO and CP teams
• Integration of behavioral health and primary care

• Identifying and partnering with community-based organizations and social services agencies
• Best practices for recruiting and hiring from the community
• Integrating social determinants of health screening into practice-level workflows
• Designing programs grounded in community-level knowledge

• Cultural competency training for providers and staff
• Strategies for empowering members to take an active role in their care
• Using technology to support members in the community
• Conducting focus groups with members with physical disabilities to better understand their care needs and preferences
• Leveraging the input of patient and family advisory boards

• Developing and/or implementing workflows and data capture methodologies related to members’ Flexible Services screening
• Identifying and engaging Social Services Delivery Entities (SSDE) that meet provider qualifications and have the capacity to provide Flexible Services supports to members in their service area(s)
• Developing business and data sharing agreements with SSDEs

• Refining electronic health records (EHR), registries, and other reporting and tracking tools
• Aligning health information exchange tools across practice sites
• Aligning data fields and reporting to reflect new workflows

Includes strategic planning, leadership and change management coaching, innovations in care delivery, administrative efficiency and effectiveness, and quality improvement

• Strategic planning to align practice-level priorities with broader organizational goals
• Coaching and professional development on managing change for ACO, CP, or practice-level leadership
• Developing and implementing telehealth or group visit models
• Re-designing scheduling processes
• Designing and implementing quality improvement programs

Includes risk stratification, data analytics, and care planning

• Designing or improving risk stratification and patient identification models
• Developing interventions tied to claims data
• Developing and implementing chronic disease management programs

Includes developing strategies for, supporting the implementation of, and training staff and providers in telehealth

• Support for conducting a comprehensive telehealth needs assessment
• Developing and implementing protocols and controls to ensure that telehealth activities comply with all relevant laws and regulations
• Clinical workflow redesign and implementation grounded in evidence-based telehealth guidelines and best practices
• Support for designing a culturally and linguistically competency member engagement and education strategy and related materials specific to telehealth

Includes role-specific training and development

• Developing or engaging in role-specific training programs – e.g. medical assistants, care coordinators
• Designing and implementing apprenticeship programs