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Practice Transformation 

Practice transformation is the process of changing healthcare delivery to ensure all of a patient’s needs are being met in a convenient, timely manner.


It is a multi-faceted and continuous process that requires healthcare providers to analyze and change their internal operations, collaborate with other providers, and extend themselves further into the community to increase visibility and access for their patients.

FDRHPO has been providing comprehensive practice transformation services and support to healthcare providers in the North Country since 2010. Our Practice Transformation team works with hospitals, private primary care offices, federally qualified health centers, behavioral health providers, and community-based organizations on an individual basis, taking into account facility size, services provided, staff concerns and other nuances. We believe this personalized approach is necessary to truly embrace and achieve transformation goals.


Our Practice Transformation Strategies

Practice transformation doesn’t occur overnight — it’s a long-term investment and can take years to come to fruition. It requires plenty of planning, organization, and maintenance. So, how do we help our region achieve its practice transformation goals? 

Using Electronic Health Records and the Health Information System

Every time a patient visits a hospital, doctor’s office, dentist, or other healthcare provider, information about that patient’s health is recorded to maintain an accurate record of his or her medical history. Most often, this information is stored electronically, in what is called an Electronic Health Record, or “EHR” for short.

Implementing EHRs in all of our region’s medical offices is the first step in our practice transformation journey, and connecting them all through a Health Information Exchange (HIE) is the second. Currently, all of our region’s healthcare providers use EHRs, and more than 95% are connected through the HIE — including all primary care providers.

Why this strategy?  Simple — healthcare providers need to communicate for practice transformation to occur, and it helps if they are speaking the same language. EHRs and the HIE enable healthcare providers to stay up-to-date on their patients, no matter where they receive care in the community. These tools also allow providers to easily refer their patients to additional services, sending along relevant information with the referral. Information is shared quickly and securely, improving the speed, quality and cost of a patient’s care.

Harnessing Data to Affect
System-Wide Change

FDRHPO and its partner NCI utilize technology to aggregate patient health information from a variety of sources — such as EHRs, insurance claims, and others — and analyze it to track and improve clinical outcomes while lowering costs. This endeavor supports our region’s participation in value-based payment contracting and current and future practice transformation incentive programs. All patient data collected through this process is mandated by state and federal law to be protected.

Taking Advantage of Telemedicine

Especially in our rural region, not all patients live near the hospital or medical specialist they need access to. That’s why telemedicine is an important strategy for practice transformation.

Just like a video chat allows friends and family to stay in touch from long distances, telemedicine allows a patient to reach out to a healthcare provider located miles away. Using telemedicine, a patient can visit his or her local primary care office and connect electronically with a healthcare provider in another town, county or state. That specialist can securely diagnose, counsel and provide care for the patient using video conferencing and other telemedicine equipment, saving the patient time, money and the burden of travel.

To learn more about telemedicine and what’s available in our region, visit the Telemedicine page on this website.

Implementing Care Management
& Care Coordination

Care managers and care coordinators are like the concierges of healthcare and thus play a very important role in the practice transformation process. They help individual patients navigate the healthcare system, set goals for their health and wellness, and monitor their progress, adapting plans as the patient’s needs change.

Care coordination is identified by the Institute of Medicine as a key strategy that has the potential to improve the effectiveness, safety, and efficiency of the American healthcare system. Well-designed, targeted care coordination that is delivered to the right people can improve outcomes for everyone: patients, providers, and payers. 

FDRHPO works with its partners to optimize chronic care management (CCM) and transitional care management (TCM), identifying patient candidates for CCM, facilitating the delivery of admission/discharge/transfer (ADT) alerts, and more. 

Building Patient Centered
Medical Homes

The Patient-Centered Medical Home (PCMH) is a model of primary care that focuses on patient-centered care, communication among providers, elimination of duplicate tests and procedures, and greater patient education and access. The PCMH model is a cornerstone of practice transformation, and FDRHPO has been helping practices become PCMH recognized since 2010.

According to the National Committee for Quality Assurance, which regulates policies and guidelines, there are six criteria of recognized PCMH practices:

  1. Team-Based Care and Practice Organization: Helps structure a practice’s leadership, care team responsibilities and how the practice partners with patients, families and caregivers.

  2. Knowing and Managing Your Patients: Sets standards for data collection, medication reconciliation, evidence-based clinical decision support and other activities.

  3. Patient-Centered Access and Continuity: Guides practices to provide patients with convenient access to clinical advice and helps ensure continuity of care.

  4. Care Management and Support: Helps clinicians set up care management protocols to identify patients who need more closely managed care.

  5. Care Coordination and Care Transitions: Ensures that primary and specialty care clinicians are effectively sharing information and managing patient referrals to minimize cost, confusion and inappropriate care.

  6. Performance Measurement and Quality Improvement: Helps practices develop ways to measure performance, set goals and develop activities that will improve performance.


All of our clinically-integrated network's primary care practices have achieved the highest available NCQA PCMH recognition. 

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