PCMH, QPP, TCPI, CPC+, ACOs – our practices are inundated with an alphabet soup of programs pushing us to improve.

At the most basic level, all these programs share a goal to achieve the Quadruple Aim of better population health, improved health outcomes, lower costs, and a joyful healthcare workforce. In the field, however, each program has its own areas of focus, expectations and levels of support, making it difficult for primary care practices to understand what it will take to succeed in one or more programs.

Use this tool to see how the programs focus across the fundamental building blocks of advanced primary care and make choices about which support programs and projects are best for their unique needs.

Health of Populations

Includes improving health and functional status, lowering the incidence and prevelance of diseases across a population, and prolonging life expectancy.

Experience of Care

Improved experience surveys scores. Making measurable improvements in safety, effectiveness, timeliness, efficiency, equity, and patient-centeredness of medical care.

Per Capita Costs

Lowering the total cost of care per member per month; Reducing rates of hospitalizations and ED utlization.

Clinician and Staff Satisfaction

Promote enthusiasm for work a sense of personal accomplishment and meaning among the healthcare team.

TCPi Secondary Drivers
10 Building Blocks
Quality Payment Program (QPP)

Person and Family-Centered Care

Implement formal systems to actively engage patients and families in collaborative decisions about health goals. Maintain awareness and respect for literacy, language, and cultural preferences.

Population Management

Assign patient and care team panels. Care teams accountable for data and use of registries to stratify risk and identify care gaps for prevention or diagnoses.

Coordinated Care Delivery

Coordinate care and manage care transitions collaboratively with patients/families. Manage medication reconciliation with patients/families. Establish medical neighborhood roles. Ensure quality referrals across the medical neighborhood.

Enhanced Access

Provide 24/7 access to the care team. Provide patient and family centered scheduling options, locations and spaces.

QI Strategy Culture of Quality & Safety

Approach and build QI capacity to support the partnership of patients/families, while empowering each staff member to improve and actively participate in shared learning.

Optimal Use of HIT

Use technology to: improve access to care; share information; support care delivery and decision-making; facilitate partnerships; and support efficient practices and lower overall costs.

Workforce Vitality & Joy in Work

Hire for alignment with mission and then provide essential orientation and onboarding support. Cultivate joy in work with efficient workflows that improve patient interactions. Recognize and reward contributions.

Team-Based Relationships

Care teams effectively coordinate. Team and specialty-primary care roles defined to optimize continuity for patients. Care teams recognize each other as partners in care.

Practice as a Community Partner

Identify and assess community health needs and social determinants. Collaborate with community partners and inventory available community resources for patient use. Share performance results.

Organized, Evidence-Based Care

Whole person care according to evidence and patient needs and preferences, including social determinants of health. Implement evidence-based protocols, decrease care gaps and reduce unnecessary tests.

Engaged and Committed Leadership

Commit leadership and create a shared vision for transformation. Dedicated, visible and sustained leaders and staff understand their role in achieving the organization’s goals.

Transparent Measurement & Monitoring

Continuously use data to transparently monitor and improve performance, quality, and service. Set performance goals and benchmarks at multiple levels within the practice.

Strategic Use of Practice Revenue

Performance excellence through business practices. Budget mgmt, program ROI; patient feedback; alternative and performance payments; capability/technology investment; revenue cycle mgmt, including billing/collection processes.

Capability to Analyze & Document Value

Manage total cost of care; analyze and document value; financial data transparency; data extraction and analysis and develop team understanding of finances and business tools.

Engaged Leadership

Practice leaders support innovation and shared leadership, including proactively removing organizational barriers to change. Acknowledge that everyone is responsible for change and improvement in the practice.

Data-Driven Improvement

Quality measurement data are clean, accurate, extracted from EHR for registries and targeted conditions, used for improvement activities. Workflows maintain and sustain accurate registry data.

Patient-Team Partnership

Systematically seek patient and family input (from surveys or advisory groups), provide community and self-management support resources, collaboratively develop care plans, use shared decision making tools.

Continuity of Care

Systematically ensure patients are able to see their own clinician when possible and track percentage of patient visits that are with the patient’s personal clinician.

Comprehensiveness & Care Coordination

Systems assure follow-up and care planning during transitions of care, including collaborative agreements with specialists and resources and care coordination based on patient’s shared care plan.


Implement systematic and sustained empanelment/panel management processes to ensure patients are assigned to a personal clinician and care team. Panels are foundations for population health.

Team-Based Care

Defined care teams (with team member roles aligned with skills) meet regularly to standardize protocols and standing orders for efficient workflows. Team huddles to discuss and plan for the day’s patient visits.

Population Management

Use standardized methods to identify high-risk patients and patients that need more intensive care—such as patient recall systems, care management, or community resources.

Access to Care

Patients can: reliably access care from practice after hours/weekends; quickly access and make appointments with personal care team member(s) within defined and acceptable time periods.

Template of the Future

Offer patients options for e-visits, telephone encounters, group appointments, and visits with other team members to better “share the care” among clinicians, team, and patients.

Patient-Centered Access

Same-day appointments for routine and urgent care. Instructions for obtaining care/advice within and outside business hours, including appointment options available. Monitor no-shows to improve access.

Team-Based Care

Defined roles and process training for all team members. Regular meetings/communication focused on patient care and practice functioning, performance and QI activities.

Population Health Management

Training and assigning members of the care team to coordinate care for individual patients, support patients/families/caregivers in self-management and behavior change and manage the patient population.

Care Management

Involve patients/families/caregivers (PFC) in care and goal planning (written plan sensitive to patient preferences and functional/lifestyle) and QI activities. Evaluate PFC experiences using suggested means*.

Care Coordination & Transitions

Practice is responsible for coordinating patient care and transitions (planned and unplanned) across multiple settings. Share/exchange release consent, clinical information, discharge information, summary-of-care and follow-up.

Performance Measure & QI

Use data and monitor preventive / chronic / acute services and patient care management identified through its process and criteria. Implement CQI: Set goals, analyze and act to improve.


(#) Measures- overlapping with components of building blocks, TCPI and NCQA. Quality accounts for 60% of 2017 MIPS Performance.

Resource Use

A cost measure, CMS calculates scores (practices do not report) using the Medicare Spending Per Beneficiary measure, plus 10 episode-based measures for specific conditions/procedures.

Clinical Practice Improvement Activites

Reward clinicians for care focused on care coordination, beneficiary engagement, and patient safety. Improvement Activities account for 15 % of 2017 MIPS Performance.

Advancing Care Information

Promote patient engagement and the electronic exchange of information using certified technology. This includes Security Risk Analysis, e-Prescribing, Patient Access, Send / Request / Accept Summary of Care.