Practice Transformation Support


Transformation Services providing technical assistance in meeting Track 1 requirements for advanced primary care, such as:

  • Empanelment – calculating optimal panel size; monitoring continuity and panel management
  • Access – evaluating operational considerations for 24/7 access
  • Care Coordination – identifying high-volume/high-cost specialists; executing care coordination agreements with high-value providers
  • Patient & Caregiver Experience – implementing Patient & Family Advisory Committee, including developing committee charter, planning logistics
  • Optimal Use of Health IT – implementing CRISP tools (e.g., ENS alerts, query portal); establishing bi-directional connectivity
  • Continuous Quality Improvement – ongoing monitoring of quality and utilization metrics; supporting process improvement; facilitating monthly quality meetings with practice staff
  • Care Management Fee Investments – helping practices make best use of their portion of the care management fee
  • “Fee-for-Value” Services – supporting implementation of services such as Medicare annual wellness visits, transitional care management, advanced care planning and collaborative care, to be billed by the practice

TRACK ONE Services 


Technical assistance in meeting Track 2 requirements, including:

  • Alternative Visits – evaluating feasibility and operational considerations for offering eConsultation, telephonic and/or group visits; monitoring and assessing impact of alternative care
  • Self-Management – training staff in patient self-management support techniques; providing inventory of condition-specific self-management resources
  • Health-Related Social Needs – providing social screening tool and inventory of local resources for social determinants of health (e.g., housing instability, food insecurity, transportation, financial vulnerability, health literacy, health-harming legal needs)

More Holy Cross Health CTO Services: