The Patient Centered Primary Care Collaborative Support and Alignment Network (PCPCC SAN) was created to assist staff and leaders in Practice Transformation Networks, along with enrolled clinicians, to successfully transform their practices to deliver person and family centered care. In 2017 the TCPI is adopting 6 measures of person and family engagement (PFE). On this page, we describe the measures and offer links to websites where you can download tools, information, and other educational materials.
“Bite Sized” Exercises and Discussion Prompts to Reinforce Culture
Questions to ask your doctor about patient-centered care
The PCPCC SAN is available to help Practice Transformation Networks and TCPI-enrolled clinicians improve person and family engagement. We offer monthly training events along with our Webinar Library, and the SAN Resource Library that includes one pagers and other information you can use to get started. We will also provide one on one services whenever possible. Our SAN offers:
- Coaching calls with PFE subject matter experts
- Virtual trainings and webinars customized for your organization’s needs
- On-site speaking, training or technical assistance (if available)
- Helping to establish peer support programs as a person and family engagement strategy
- Assisting clinicians to develop community partnerships with local YMCAs that promote TCPI goals
Point of Care
1. Active e-Tool: Does the practice use an e-tool (patient portal or other E-Connectivity technology) that is accessible to both patients and clinicians and that shares information such as test results, medication list, vitals and other information and patient record data?
Resources to support performance improvement:
2. Shared Decision-Making: Does the practice support shared decision-making by training and ensuring that clinical teams integrate patient-identified goals, preferences, concerns and desired outcomes into the treatment plan (e.g. those based on the individual’s culture, language, spiritual, social determinants, etc.)?
Resources to support performance improvement:
- Institute for Healthcare Improvement: Partnering in self-management support: A toolkit for clinicians. This online toolkit includes instructions, forms and action plans for implementing a self-management improvement program. (free but registration required)
- AHRQ Patient Decision Aids
- Mayo Clinic Shared Decision Making National Resource Center
- Option Grid – Decision Aid Library
- Ottawa Personal Decision Guide
- Informed Decision Making – Informed Medical Decisions Foundation
- Ask Me 3: Good Questions for Your Good Health – National Patient Safety Foundation
- Choosing Wisely: 5 Questions to Ask Your Doctor Before You Get Any Test, Treatment, or Procedure
3. Patient Activation: Does the practice utilize a tool to assess and measure patient activation?
Patient activation refers to a “patient’s knowledge, skills, ability, and willingness to manage his or her own health and care.” [Health Affairs] Tools to measure patient activation can include the Patient Activation Measure (PAM)*, but it can also include other tools that measure a patients’ willingness and capacity to take on the role of managing their own health and health care. TCPI is striving to achieve patient activation through a broader perspective of care management aligned with the change package.
Resources to support performance improvement:
- Stanford Chronic Disease Self-Efficacy Scales
- Patient Health Engagement Scale
- Supporting people to manage their health An Introduction to patient activation J. Hibbard, H. Gilburt May, 2014