We are slowly working on redesigning the way we deliver care in our Family Medicine Center. We have focused on care of folks with chronic illness for a while but recently (with the passage of the ACA and the coming of ACOs) we are working on hitting the sweet spot.  A couple of weeks ago Dr Berwick made it easier. He published an article in the New England Journal of Medicine that identified areas of care delivery that primary care physicians will be required to focus their quality energy on in the future if they expect payment and recognition in a post-ACA world. For those, like me, who believe the future is now below are the areas where documentation of level of care (followed by improvement) in the primary care setting will be expected:

Ability of the practice to provide an enjoyable patient and caregiver experience

• Getting timely care, appointments, and information

• How well your doctors communicate

• Helpful, courteous, respectful office staff

• Patients’ ratings of doctor

• Health promotion and education

• Shared decision making

• Health status or functional status

Ability of the practice to facilitate care coordination —transitions

• Risk-standardized, all-condition readmission

• 30-Day post-discharge physician visit

• Medication reconciliation

• Care transitions measure

• Management of ambulatory-sensitive conditions: diabetes; chronic obstructive pulmonary disease (COPD); congestive heart failure (CHF); dehydration; bacterial pneumonia; urinary tract infections (UTIs)

delivery of services related to preventive health and early disease detection

• Influenza immunization

• Pneumococcal vaccination

• Mammography screening

• Colorectal cancer screening

• Cholesterol management for patients with cardiovascular conditions

• Adult weight screening and follow-up

• Blood-pressure measurement

• Tobacco-use assessment and intervention

• Depression screening

Care for members of at-risk populations —diabetes

• Composite and individual measures (glycated hemoglobin, LDL cholesterol <100 mg/dl, blood pressure

<140/90 mm Hg, tobacco nonuse, aspirin use)

• Poor glycemic control (glycated hemoglobin >9%)

• Blood pressure control in diabetes

• Screening rates for microalbuminuria

• Dilated eye exam; foot exam

Care for members of at-risk populations — heart failure

• Left ventricular function assessment

• Left ventricular function testing

• Weight measurement

• Patient education

• Heart failure prescription rates for left ventricular systolic dysfunction (LVSD)

• Angiotensin-converting–enzyme inhibitor or angiotensin-receptor blocker (ACE/ARB) rates for LVSD

• Warfarin therapy for patients with atrial fibrillation

Care for members of at-risk populations — coronary artery disease

• Coronary artery disease (CAD) composite and individual measures (oral antiplatelet therapy for patients with CAD; drug therapy for lowering LDL cholesterol; beta-blocker for patients with CAD with prior myocardial infarction; LDL cholesterol <100 mg/dl; ACE/ARB therapy for patients with CAD and diabetes, LVSD, or all of the above)

Care for members of at-risk populations —hypertension

• Blood-pressure control rates (<140/90 mm Hg)

• Hypertension plan of care

Care for members of at-risk populations— COPD

• Spirometry evaluation

• Smoking-cessation counseling

• Bronchodilator therapy based on FEV1

Care for members of at-risk populations — frail elderly

• Screening for fall risk

• Osteoporosis management in women who had a prior fracture

• Monthly INR for beneficiaries on warfarin