This module is designed to introduce you to the office-based and clinical patient-based supporting functions that, when managed collectively, lead to improved patient outcomes. These include: 1) Medical Management: Utilization, Case, Data and Pharmacy, 2) Registries, Analytics, and Technology, 3) Guidelines, Types of Evidence, and Recommendations, and 4) Coordination around SDOH/Community Resources. The world of primary care medicine is evolving rapidly. Patient expectations are changing, along with those of third-party payers and the providers themselves. Many patients are looking for “on demand” access, but others are looking for a long-term medical home. Telemedicine and telehealth are growing along with new approaches to hospital- and home-based functions. These changes all point to the idea that patients and payers are looking for value. And that “value” is not just an appointment and a paper prescription to fill at the end, but real assistance to manage chronic diseases and help patients navigate the complex world of the healthcare system. Discussion of those additional office-based supporting functions will comprise the majority of information in this module. In addition to those patients who come in for appointments, maintain regular healthcare visits, or become hospitalized, a big part in the role of supporting functions is to capture the health status of patients who have not visited in six months to a year. Utilizing panel management—a systematic, proactive approach to identify and address unmet chronic and preventive care needs of the patients a practice is responsible for—leads to better health outcomes for that patient population. Whether an office has insurer-based reporting or uses office-based record-keeping, using panel management to ask clinical patient-based questions related to immunizations, cancer screenings, or diabetes care is using the function of data/predictive analytics to support a strategy of identifying non-utilization patterns. Remember, as you read or hear terms or concepts that are new to you, have your digital (Word doc) or analog (paper) notepad handy to write them down. At any time, you can use your favorite search engine to learn more. Be a self-directed learner!

In this course, you have explored critical office-based and clinical patient-based processes and supporting functions that a value-based practice must manage collectively in the drive towards improved patient outcomes. An expectation of this course or certificate program is not for you to emerge as an expert in all of these processes—remember, it does take a team to manage them. However, it is important that you develop an understanding, beyond basic definitions, of their importance for improving patient outcomes and experience. In addition, it is important to collectively think about these processes in the context of a value-based care model. In this summative assignment, you will have the chance to reflect on what you have learned about these processes and supporting functions and their relationship to the fundamental premise of value-based care.