The Improving Primary Care Assessment is intended to help sites measure how well a their primary care teams are functioning and to point toward improvements covered by the topics on this website. The Improving Primary Care Assessment can also help sites track progress toward practice transformation when it is completed at regular intervals.
This assessment was developed by the MacColl Center for Health Care Innovation at Group Health Research Institute. It is based on the PCMH-A measures created by MacColl in collaboration with Qualis Health for the Safety Net Medical Home Initiative and supplemented by measures developed by Dr. Tom Bodenheimer related to his “10 Building Blocks of High-Performing Primary Care.”
What Do Your Choices Mean?
- If you score in Level D in any area, your practice is just getting started and may want to review the tools and resources in that section of the Guide to help you prepare for the key changes described there.
- If you score in Level C in any area, your practice is in the early stages of change and can benefit from the action steps and resources in that section of the guide.
- If you score in Level B in any area, your practice has implemented basic changes and can build upon your success with the action steps and resources in that section of the guide.
- If you scored in Level A in any area, your practice has achieved most or all of the important changes required. Congratulations! You can still use the actions steps and resources in that section of the guide to find new ways to improve.
Build the Team
Assessments for The Practice Team
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Clinical leaders...
Level C
Level B
Quality improvement activities are conducted by...
Staff other than PCPs...
Clinical support staff...
Workflows for clinical teams...
The practice...
Level D
Level C
Level B
Standing orders that can be acted on by non-independent providers under protocol...
Assessment for The Medical Assistant (MA)
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MAs in our practice...
Level C
Level B
Assessment for The Registered Nurse (RN)
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RNs in our practice...
Level B
Assessment for The Lay Person
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Laypersons in our practice...
Level C
Level B
Assessment for The Clinical Pharmacist
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A pharmacist(s)...
Level B
Assessment for The Behavioral Health Specialist
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Behavioral health services...
Do the Work
Assessment for Enhancing Access
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Patients are encouraged to see their paneled provider and practice team...
Level B
Assessment for Self-Management Support
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Self-management support...
Assessment for Population Management
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Registry information on individual patients...
Level C
Level B
Assessments for Planned Care
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Visits...
Level C
Level B
A patient who comes in for an appointment and is overdue for preventive care (e.g., cancer screenings)...
Level C
Level B
Level A
Assessments for Care Management
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Follow-up by the primary care practice with patients seen in the emergency room (ER) or hospital...
Level D
Clinical care management services for high-risk patients...
Assessment for Medication Management
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In our practice medication management consists of...
Level C
Level B
Assessment for Referral Management
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Patients in need of specialty care, hospital care, or supportive community-based resources...
Level D
Level B
Assessment for Behavioral Health Integration
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Behavioral health services...
Assessments for Communication Management
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Contacting the practice team during regular business hours...
Test results and care plans...
Level B
Assessment for Clinic-Community Connections
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Linking patients to supportive community-based resources...