Learning Center

  • Partner Training
  • Partner Resources

Welcome to the Partner Training area of the Learning Center. Please click on the boxes below to access the Partner Training modules. By selecting a training module, you will be directed to new webpage where you will be able to view and complete the educational module. Please note that supported browsers for these training modules include Chrome, Firefox, and Safari.

  • Cardiovascular Health & Diabetes Wellness & Self-Management
  • Care Coordination Methodology
  • Community Health Activation Program (CHAP) Training
  • Community Orientation
  • Compliance and HIPAA Program
  • Cultural Competency, Health Literacy
  • Skilled Nursing Facilities: INTERACT
  • Skilled Nursing Facilities: Long Term Care Performance Improvement Educational Series
  • Interventions for Tobacco Cessation
  • Partner Reporting Webinar DY3Q2
  • Promoting Asthma Self-Management
  • Performance Reporting and Improvement
  • Population Health
  • Primary & Behavioral Health Integrated Care
  • Screening, Brief Intervention and Referral to Treatment (SBIRT)
  • Transition of Care Program for Inpatient & Observation Units

Cardiovascular Health & Diabetes Wellness & Self-Management Programs Learning Module

This module reviews the evidence-based resources and treatment strategies being implemented to support the Cardiovascular Wellness and Self-Management Program and the Diabetes Wellness and Self-Management Program. You will learn about the Million Hearts® campaign, tools available to identify patients in need of follow-up care, how to successfully retrieve accurate blood pressure readings and teach self-monitoring blood pressure techniques, and methods to reduce tobacco use in patients. You will also learn about tools available to identify patients with diabetes or “at-risk” of developing diabetes, comprehensive diabetes testing methods and lifestyle recommendations. Finally, you will learn about documentation of patient self-management goals and how to refer patients to self-management education. DSRIP partners are expected to review each curriculum presentation and attest that they understand the training.

Cardiovascular Wellness & Self-Management Program

Learning Objectives:
  • Demonstrate the elements of the DSRIP Cardiovascular Wellness & Self-Management Program
  • Recall major strategies, goals, and tools of the Million Hearts® campaign
  • Recognize how a registry is used to identify and track hypertension patients
  • Summarize key points from guideline recommendations

Blood Pressure Measurement (practice-based or self-monitored)

Learning Objectives:
  • Summarize proper techniques and equipment for measuring Blood Pressure
  • Identify implications of performing blood pressure measurements incorrectly
  • State the impact of self-monitored BP programs (SMBP) in reducing risk of disability or death due to uncontrolled hypertension
  • Identify features to consider in guiding patient in selection of SMBP equipment
  • Review the validation process for automatic blood pressure measurement devices

Diabetes Wellness & Self-Management Program

Learning Objectives:
  • Review the impact of diabetes
  • Define the elements of the Diabetes Wellness & Self-Management Program
  • Apply the screening and treatment recommendations for patients with diabetes

Patient Self-Identified Goals and Diabetes & Chronic Disease Self-Management Education

Learning Objectives:
  • Formulate ‘smart goals’ in collaboration with patient
  • Illustrate Motivational Interviewing techniques to assist patients in setting health goals
  • Identify benefits of diabetes and chronic disease self-management education, components of self-management programs, and the various programs to which a patients can be referred

Care Coordination Methodology, Protocol & Treatment Plans Learning Module

This module provides an overview of Care Coordination and its place in the health care delivery system. Emphasis is placed on the importance of coordinated care throughout the continuum and how social determinants of health can impact a patient’s health outcomes. Participants will gain an understanding of who can coordinate care, how this is accomplished through transitions of care, and the importance of providing patients with effective, efficient, patient centered care.

Understanding the Basic Principles and Core Elements of Care Coordination

Learning Objectives:
  • Understand and define what it means to coordinate care
  • Describe those members of the care team that coordinate care and how they work as in interdisciplinary team
  • Understand the importance of coordinating care throughout the care continuum
  • Describe basic barriers to reaching optimal health outcomes and explain ways in which these barriers can be overcome
  • Understand the difference between care coordination and care management

Understanding the Purpose and Benefits of Successful Patient Hand-Offs

Learning Objectives:
  • Understand effective and ineffective transitions in care
  • Describe the root causes of ineffective transitions
  • Describe various models of transitions of care
  • Understanding a warm hand-off & benefits of warm hand-offs, referrals and transfers

Integrated Delivery System (IDS) 101

Learning Objectives:
  • Understand the definition and meaning of an Integrated Delivery System
  • Understanding the SCC Clinical Integration Strategy
  • Describe the various levels of care coordination occurring throughout the care continuum
  • Understand how the DSRIP projects enhance the ability for care to be coordinated
  • Identify and differentiate between care coordination and more specialized, complex care management occurring at various levels of the integrated delivery system

Community Health Activation Program (CHAP) Training Module

This learning module provides training for community health workers, health coaches, health care providers and clinicians on participating in the CHAP program and patient activation techniques. The CHAP program focuses on persons who are uninsured or low utilizers or non-utilizers of the health care system and works to engage and activate those individuals to utilize primary and preventive care services. Through evidence-based patient activation activities, you will identify individuals and measure and improve their health literacy and level of activation, thereby encouraging active management of their personal health. Participants of training will be introduced to the CHAP program requirements which includes administering the PAM Survey, the Wellness Coaching Model, and Community & Primary Care Provider Navigation. Participants are expected to review each curriculum presentation and attest that they understand the training though a few competency questions following each topic. Participants must complete all topics within the learning module to become a PAM Provider under the CHAP Program.

Becoming a Patient Activation Measure (PAM) Provider

Learning Objectives:
  • Learn about the Suffolk Care Collaborative, the Delivery System Reform Incentive Payment Program and the Community Health Activation Program.
  • Training in administering and documenting PAM surveys, including how to appropriately assist project beneficiaries using PAM.
  • Gain expertise in patient activation and engagement including shared decision making, motivational interviewing, techniques such as OARS, and measurements of health literacy and cultural competency.
  • Learn about the Coaching for Activation tools, techniques and content.
  • Understand the NYS Health Home Model and eligibility criteria for targeted populations.
  • Learn about Suffolk County’s areas of high need for targeted outreach and community navigation.
  • Training in connectivity to healthcare coverage, community healthcare resources and patient education.
  • Gains an understanding of Insignia Information Software.

Patient Activation Measure (PAM) and Wellness Coaching by Insignia Health

Learning Objectives:
  • List the three domains of “Activation”
  • List the two types of metrics associated with PAM.
  • Name behavioral characteristics of each of the four levels.
  • List ways that CFA can assist you in working with an individual.
  • Learn about the Coaching for Activation tools, techniques and content.
  • Gain expertise in patient activation and engagement including shared decision making, measurements of health literacy and cultural competency.

Community Orientation Learning Module

This module provides an overview of the Suffolk County Community, its needs and Suffolk Care Collaborative (SCC) initiatives. It explores how the SCC aims to focus multiple initiatives and strategies for the high priority needs in Suffolk County to prevent chronic disease, promote mental health and prevent substance abuse. Participants will gain a better understanding of the population characteristics and demographics, understand and learn about strategies to address areas of need, and also how the Suffolk Care Collaborative is connecting target populations and families to health and wellness services within the community.

Community Orientation

Learning Objectives:
  • Understand the population characteristics and demographics of Suffolk County
  • Identify and understand the priority areas/needs in Suffolk County community and the relationship to the chosen clinical projects through our Community Needs Assessment.
  • Identify areas of need in order to better target the intended recipients
  • Identify the individuals and communities where avoidable utilization of high-cost health care resources currently exist.
  • Learn about the SCC and HITE partnership

Compliance and HIPAA Program Learning Module

This module presents essential information about the SCC’s Compliance and HIPAA Program including information privacy and security, ethics, Code of Conduct, confidential reporting, the legal framework for compliance, and how to get more information when you need it. Attention is also given to the relationship between Coalition Partners and the SCC in the implementation of the Compliance Program.

Compliance

Learning Objectives:
  • Understand the scope and requirements of the SCC Compliance Program and how to get information when you need it
  • Read and acknowledge the SCC Code of Conduct
  • Understand the duty to report compliance concerns and how to do so confidentially
  • Know that retaliation against good faith reporters is prohibited
  • For SCC personnel only: complete a Conflict of Interest disclosure form

HIPAA Privacy

Learning Objectives:
  • • Describe the Health Insurance Portability and Accountability (HIPAA) Privacy Rule
  • • Describe Individually Identifiable Health Information (PHI)
  • • Describe Protected Health Information (PHI)
  • • Understand the basic responsibilities of Business Associates (BAs)
  • • Understand Patient Rights under HIPAA

HIPAA Security

Learning Objectives:
  • Understand the Health Insurance Portability and Accountability (“HIPAA”) Security Rule and e-PHI
  • Describe the Health Information Technology for Economic and Clinical Health Act (“HITECH”)
  • Understand the basic responsibility of Business Associates (BAs)
  • Understand Administrator Requirements of the HIPAA Security Rule
  • Describe a Breach Notification/Assessment/Impact
  • Understand the basic responsibilities of Subcontractors
  • Understand investigations and consequences of HIPAA violations
  • Describe HIPAA case studies

Cultural Competency Health Literacy Learning Module

This module establishes an overview of concepts used to enhance both patients’ and providers’ understanding of the health care system. It emphasizes the terms cultural competency and health literacy. These terms enable the differing cultural needs of patients to be recognized while not overlooking a patients’ true understanding of their overall health and well-being. The social determinants of health will also be analyzed in order to further patients’ knowledge of their unavoidable risks with in the health care system.

Cultural Competency, Health Literacy 101

Learning Objectives:
  • Define health literacy and cultural competency
  • Discuss the scope and the challenges of health literacy and cultural competency and why it is important.
  • Understand how culture, health literacy and language access influence patient-centered care.

Skilled Nursing Facilities: INTERACT Learning Module

This module provides an overview of the SCC INTERACT Program. It focuses on an introduction to INTERACT and describes implementation program and requirements. Participants will gain a better understanding of how to educate and train staff on the basics of the INTERACT Quality Improvement Program, INTERACT tools, and the Facility Champion roles and responsibilities that will facilitate and act as the INTERACT coach for each facility.

INTERACT Overview and Tool Highlights

Learning Objectives:
  • Understand current landscape of health care reform and funding that make the INTERACT QIP an essential initiative.
  • Understand the INTERACT Coaching Program/Facility Champion within your facility.
  • Understand key strategies that form foundation of the INTERACT QIP tools & resources.
  • Understand how to properly utilize: Stop & Watch Early Warning Tool & SBAR Communication Tool
  • Understand your Facility Champion will continue training on: Care Pathways & Clinical Tools &Advanced Care Planning Tools

INTERACT Quality Improvement & Assurance Program

Learning Objectives:
  • Understand current landscape of health care reform and funding that make the INTERACT QIP an essential initiative.
  • Understand the INTERACT QIP Quality Improvement tools related Rehospitalizations and RCA’s.
  • Understand key strategies that form foundation of the INTERACT QIP tools & resources to allow cultural transformation
  • Understand INTERACT QIP Advanced Care Planning tools

Skilled Nursing Facilities: Long Term Care Performance Improvement Educational Series Learning Module

This educational series provides learning topics to support skilled nursing facilities in performance improvement focus areas. Participating SNFs identified areas of improvement in their Quality Improvement Action Plans, including: Early Warning Signs of Sepsis/UTI, INTERACT Tools Implementation, Fall Reductions Initiatives, Advanced Care Planning/MOLST/eMOLST Initiatives and Alzheimer’s/Dementia Training. These will be the topics of focus for this educational series. Participants will gain a better understanding of each topic with a general overview, tools and resources to utilize and best practices and real-life examples to facilitate practical learning.

Early Recognition of Infection in Long Term Care Settings

Learning Objectives:
  • Highlight the importance of early recognition of infection in the long-term care setting.
  • Utilize real-life examples to further understand how to recognize the onset of infection.
  • Apply the INTERACT Tools to the practice of early infection recognition.
  • Understand the definition of Sepsis and early warning signs.
  • Provide first steps for treatment after identifying sepsis.

Interventions for Tobacco Cessation Learning Module

This module is intended to support trainees in understanding interventions for tobacco cessation to support the SCC’s clinical improvement programs and population-wide wellness initiatives. You will learn about Tobacco Cessation control methods endorsed by the Million Hearts® campaign as well as understanding the services provided through the NYS Smokers’ Quitline. You will also learn about tobacco use prevalence, tobacco dependence and the evidence based cessation treatments for individuals with mental illness and/or behavioral health disorders.

5 A’s of Tobacco Cessation Control and Referring to the NYS Quitline

Learning Objectives:
  • Summarize the 5 A’s of tobacco cessation counseling
  • Describe the services of the NYS Smokers’ Quitline and the referral process
  • Illustrate how Progress Reports are obtained and the information included in the reports
  • Discuss the role of patient-center communication in providing effective tobacco counseling
  • Provide evidence-based brief interventions in counseling tobacco users

Tobacco Dependence and Cessation Treatment in Individuals with Mental and/or Behavioral Disorders

Learning Objectives:
  • Identify strategies that individuals with mental and/or behavioral health disorders may use to support their efforts to quit using tobacco products.
  • Define the 5A’s for treating tobacco dependence as outlined in the US PHS Guideline Treating Tobacco Use and Dependence.
  • Identify the FDA approved medications used to treat tobacco dependence for patients who use tobacco products and increase the rate of successful quit attempts.
  • Evaluate various resources available to assist patients to quit.
  • Summarize the 5R’s to enhance motivation to quit using tobacco products.

Tobacco Dependence and Cessation Treatment: The Individual with Diabetes

Learning Objectives:
  • Define diabetes and summarize health effects of tobacco use in patients with diabetes.
  • Review the US Public Health Service Guidelines for treating tobacco use and dependence.
  • Identify the FDA approved medications to treat tobacco and nicotine dependence.
  • Define and relapse prevention strategies for patients struggling to remain smoke free.
  • Examine the various resources available to assist patients to quit tobacco use.

Partner Reporting Webinar DY3Q2

This webinar details reporting requirements for Patient Engagement for DSRIP Demonstration Year 3, Quarter 2. This webinar outlines important information and timelines for Partner Data Requests due to the SCC on October 13, 2017.

Partner Reporting Webinar DY3Q2

Learning Objectives:
  • Describe the DSRIP Domain 1 Patient Engagement reporting requirements and commitments made to the Department of Health
  • Identify the SCC data request timeline and DOH reporting schedule
  • Explain the patient engagement data specs needed by DSRIP project
  • Discuss the strategy for transmitting Protected Health Information (PHI) to the Suffolk Care Collaborative to meet Patient Engagement Quarterly Reporting Requirements

Promoting Asthma Self-Management

The Home-Based Asthma Self-Management program is a component of the Promoting Asthma Self-Management Program (PASP). The home-based self-management program is designed for children and young adults under the ages of 26, with asthma. There are several organizations that provide this service within the PPS for eligible patients. Patients enrolled receive home visits from trained health care workers in order to learn how to better manage their asthma or their child’s asthma independently. This module provides an overview of the program as well as eligibility criteria.

Promoting Asthma Self-Management Program: Home-Based Self-Management

Learning Objectives:
  • Recognize the value of home-based asthma interventions
  • Become knowledgeable about PASP eligibility criteria
  • Understand the structure of a home visit
  • Become familiar with how nurses/community health workers can help patients
  • Learn how to make a referral to the appropriate home-visitation program

The American Lung Association’s Asthma Basics Course

Learning Objectives:
  • Recognize and manage triggers
  • Understand the value of an asthma action plan
  • Recognize and respond to breathing emergency
  • View the What is Asthma? Animation that shows the three primary changes in the airways during an asthma episode
  • Learn about comprehensive resources, including asthma medication devices and demonstration video downloads for patients
View What is Asthma? Animation and asthma medication devices and demonstration video by clicking on Resource button below:

Performance Reporting and Improvement Learning Module

This module provides an overview of the SCC Performance Reporting and Improvement Program. It focuses on an introduction to the SCC Performance Reporting and Improvement Program and describes the Domain 1 Patient Engagement Reporting Requirements. Participants will gain a better understanding of how to deploy PDSA cycles to conduct tests of change and utilize control charts to understand data variation.

The SCC Performance Reporting & Improvement Program

Learning Objectives:
  • Describe the purpose of the SCC Performance and Improvement Plan
  • Define the SCC approach to the Rapid Cycle Improvement
  • Discuss the performance reporting organizational structure and stakeholder roles and responsibilities
  • Identify the 11 DSRIP Projects the SCC is implementing across Suffolk County
  • Explain the performance reporting requirements for Domain 1 Patient Engagement, Domain 1 Project Engagement, and Domain II & III Performance Outcomes
  • Discuss the Pay-for-Reporting (P4R) and Pay for Performance (P4P) model and associated timeline
  • Explain the Gap-to-Goal improvement standards
  • Describe the SCC approach to data aggregation and analysis including the decision support tools used to support the performance reporting program
  • Explain the SCC action planning process
  • Describe the SCC recommended model for performance improvement (IHI Improvement Model)

IHI – An Introduction to the Model for Improvement

Learning Objectives:
  • Describe the Model for Improvement
  • Discuss how to use the Plan-Do-Study-Act (PDSA) cycle to conduct rapid tests of change
  • Explain the three questions that can help drive quality improvement work

IHI – Building Skills in Data Collection and Understanding Variation

Learning Objectives:
  • Describe how to evaluate data variation
  • Explain Common and special causes of variation
  • Identify data collection strategies

IHI – Using Run and Control Charts to Understand Variation

Learning Objectives:
  • Describe the history of how statistical processes control (SPC) methods evolved over time
  • Identify three key questions to construct and use a control chart
  • Explain how to select the appropriate control chart based on the types of data

Population Health Learning Module

This module provides an overview of the New York State’s Delivery System Reform Incentive Payment Program (DSRIP). It focuses on the overall goals of the program, provides an overview of the SCC structure and discusses the SCC Quality Improvement Agenda.

DSRIP 101

Learning Objectives:
  • Discuss the goals of DSRIP
  • Identify what a Performance Provider System is and its purpose
  • Describe the Suffolk Care Collaborative's Structure
  • Recognize the 11 SCC DSRIP Projects
  • Discuss the Suffolk Care Collaborative's Quality Improvement Agenda and Sustainability Plan

Primary & Behavioral Health Integrated Care Learning Module

This module provides a comprehensive look at the process of primary and behavioral health integration. The modules progress though understanding the core concepts related to integrating services, and the prevailing models on integration and their relation to population health, to preparing for integration, and finally to full implementation and documentation. Participants will gain a full understanding of the potential of this type of integration to improve the health outcomes of patients, and what the steps will be to work towards this integration.

Basics of Integrated Care

Learning Objectives:
  • Describe the population based goals of integrated care
  • Describe the continuum of integrated care
  • Name the core competencies for providers in an integrated care approach

Basics of Bidirectional Integrated Care

Learning Objectives:
  • Describe the basic parameters of bidirectional programs
  • Identify the common goals of bidirectional interventions
  • Identify the core factors that make bidirectional programs effective

Primer on Evidence Based Models of Integrated Care

Learning Objectives:
  • Name and describe the three prevailing models of integrated care
  • Describe the meaning behind the constructs of levels of integration and population penetration
  • Describe the difference between models and programs

Rating Your Level of Integrated Care Using the MeHAF

Learning Objectives:
  • Describe the team members required for self-administering the MeHAF
  • Describe the core competencies of the MeHAF
  • Self-administer the MeHAF rating scale

Primer on Screening for Integrated Care

Learning Objectives:
  • Identify the typical tools used in primary care
  • Describe the concepts of screening, assessment and tracking
  • Describe implementation considerations for establishing screening pathways

Working with the Behavioral Health Clinics: The Warm Handoff

Learning Objectives:
  • Describe the function of a warm handoff
  • Describe the strategies often used to manage flow in a primary care setting
  • Describe a sample introduction that a primary care provider can use to introduce services to a patient

Documentation for Primary Care

Learning Objectives:
  • Describe the components of a primary care specific SOAP note
  • Describe elements that do not belong in a primary care record
  • Describe regulatory parameters that may influence the content of a SOAP note

Primer on the Primary Care Consult

Learning Objectives:
  • Describe the core components of a typical consult
  • Describe the content of an effective introduction
  • Describe the content of an effective functional analysis

Primer on the PCBH Model

Learning Objectives:
  • Describe the core attributes of the PCBH model
  • Describe the goals and core metrics of a PCBH service
  • Describe the core competencies of a BHC in this model

Registry Basics

Learning Objectives:
  • Describe the difference between a spreadsheet and a database
  • Describe the way in which registries are used to manage care
  • Describe considerations for implementing a registry based care pathway

Improving Screening and Identification in Pediatric Practices

Learning Objectives:
  • Name the percentage of children who have identifiable behavioral health conditions
  • Describe the components of the AAP Mental Health Toolkit
  • Describe the elements to consider when implementing screening

Primer on Pediatric Consults for Primary Care

Learning Objectives:
  • Describe the areas where primary care consultation can be effective
  • Describe the strategies for engaging pediatric patients
  • Describe the core competencies of a pediatric behavioral health consultant

Screening, Brief Intervention and Referral to Treatment (SBIRT) Learning Module

This module will provide an overview of the Screening, Brief Intervention, and Referral to Treatment (SBIRT) program. SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with substance use disorders, as well as those who are at risk of developing these disorders. Participants will gain an understanding of the SBIRT program and its components, as well as have the opportunity to become certified in SBIRT through a 4-hour, online, New York State Office of Alcoholism and Substance Abuse Services (OASAS) SBIRT training.

NYS SBIRT Introduction

Learning Objectives:
  • Outline the need for SBIRT in New York State
  • Define SBIRT and identify its defining characteristics
  • Understand how SBIRT can be utilized to screen for alcohol and/ or drug use
  • Examine how SBIRT can be implemented in the ED

CPI – 4-Hour SBIRT Training Program

Here you will connect to a free, online interactive SBIRT training for healthcare professionals offered by the Center for Proactive Innovations. You will need to create a username and Password to join the CPI’s Learning Community. Upon completion of this training, licensed health professionals will be certified to administer SBIRT.

Learning Objectives:
  • Define the need for drug and/or alcohol screening for all patients
  • Identify the fundamental components of SBIRT
  • Gain and understanding of evidence based screening tools for drug and alcohol use, and how to administer and score them
  • Become familiar with Motivational Interviewing techniques
  • Describe best practices for referring patients to treatment

Transition of Care Program for Inpatient & Observation Units Learning Module

Your hospital staff will have an increased knowledge base of DSRIP, performance measuring, the Suffolk Care Collaborative Transitions of Care Model, which includes understanding the care record transition protocol, post-discharge protocols for transitions of care providers and Health Home eligibility and navigation. These modules will your staff in creating the best discharge plan for every patient which qualifies for 30-day transitions of care services.

Understanding DSRIP & SCC’s Transition of Care Program

Learning Objectives:
  • Describe the Suffolk Care Collaborative’s Transition of Care Program Objectives
  • Understand the need for a Care Transition Intervention Model in Suffolk County
  • Identify key trends in high risk populations
  • Understand the key themes of an effective Care Transition Intervention Model

Transition of Care for Inpatient & Observation Units Program

Learning Objectives:
  • Understand the guidelines of the SCC’s Transition of Care Model
  • Understand how to define and identify patients at high risk of readmission
  • Understand the value of a Social Needs Screening
  • Understand the short stay protocol (observation unit discharges)
  • Understand the navigation and value of partnerships with home care services, health homes, care management agencies or other community agencies
  • Understanding your network of social services, including medically tailored home food services to be provided to patients during care transitions

Communication Lines & Care Record Transition

Learning Objectives:
  • Understanding the Care Record Transition Protocol
  • Understanding the Care Record Transitions Workflow Diagram

Post-Discharge Protocol for Transitional Care Providers

Learning Objectives:
  • Timely updates to community-based provider/primary care physician
  • Define the post-discharge protocol for Transitional Care Providers

Introduction to Health Homes, Eligibility & Navigation

Learning Objectives:
  • Understanding what is a Health Home
  • Understanding how a patient is eligible for Health Home enrollment as required under the ACA how to navigate a patient to a Health Home
 

A glossary containing definitions and explanations of many of the terms and abbreviations within our site is available and regularly updated on New York’s Department of Health website.

View the Glossary

Welcome to the Partner Resources area of the Learning Center. Please click on the boxes in the left hand navigational panel to access authoritative resources and opportunities for continuing education.

  • Cultural Competency
  • Health Literacy
  • PCMH
  • NYS DOH DSRIP Program

Cultural Competency

General Cultural Competency Information

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Health Literacy

General Health Literacy Information

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PCMH

Project Resources and Quick Links

AHRQ Primary Care Practice Facilitation Curriculum – “support the development of a PCPF workforce prepared to help transform and revitalize primary care by supporting widespread adoption of new models of care delivery and the use of continuous quality improvement to improve health care outcomes”
 
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