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U.S. Department of Health and Human Services
IHS Office of Quality

Change Package

The IPC Change Package, a step-by-step guide to enhancing the delivery of IPC, is adapted from the Safety Net Medical Home Initiative change package, a widely recognized and tested Patient Centered Medical Home (PCMH) change package.

IPC Change Package - steo-by-step guide illustration

Laying the Foundation

Engaged Leadership

  • Provide visible and sustained leadership to lead overall culture change, as well as specific strategies to improve quality and integration while sustaining change.
  • Visibly support improvement at all levels of the organization, beginning with senior leaders and extending throughout.
  • Ensure that the PCMH transformation effort has the time and resources needed to be successful.
  • Ensure that providers and other care team members set aside time to conduct activities beyond direct patient care that are consistent with the medical home model.
  • Build the practice’s values of creating a medical home for patients into staff hiring and training processes.

Quality Improvement Strategy

  • Use the Model for Improvement as a formal model for quality improvement.
  • Establish and monitor metrics to evaluate improvement efforts and outcomes; ensure all staff members understand the metrics for success.
  • Build capability in all staff to support improvement and ensure that patients, families, providers and care team members are involved in quality improvement activities.
  • Ensure opportunities for community members to engage in the improvement process, program development and policy.
  • Optimize use of health information technology, such as the Resource and Patient Management System (RPMS).
  • Use data to continuously improve performance, quality and service (iCare).
  • Build the practice's analytic capability.

Building Relationships

Empanelment and Population Management

  • Assign all patients to a provider panel and confirm assignments with providers and patients; review and update panel assignments on a regular basis.
  • Assess the practice's supply and demand; balance patient load accordingly.
  • Use panel data and registries to proactively contact, educate and track patients by disease status, risk status, self-management status, community and family need.
  • Use a formal data-driven approach to stratify the level of risk for all empaneled patients.

Continuous and Team-based Healing Relationships

  • Establish and provide organizational support for care delivery teams accountable for the patient population/panel.
  • Link patients to a provider and care team so both patients and the provider/care team recognize each other as partners in care.
  • Ensure that patients are able to see their provider or care team whenever possible.
  • Define roles and distribute tasks among multidisciplinary care team members to reflect the skills, abilities and credentials of team members.

Changing Care Delivery

Organized, Evidence-based Care

  • Use planned care according to patient needs.
  • Ensure high-risk patients are receiving appropriate care and case management services.
  • Use point-of-care reminders based on clinical guidelines.
  • Enable planned interactions with patients by making up-to-date information available to providers and the care team at the time of visit.
  • Support alternative and complementary medicine approaches, including traditional healing.

Patient-centered Interactions

  • Respect patient and family values and expressed needs.
  • Encourage patients to expand their role in decision making, health-related behaviors and self-management.
  • Communicate with patients in a culturally appropriate manner, in a language and at a level the patient understands.
  • Engage patients and families in goal setting, action planning, problem solving and follow action plans.
  • Provide self-management support at every visit through goal setting and action planning.
  • Obtain feedback from patients/family about their health care experience and use this information for quality improvement.

Reducing Barriers to Care

Enhanced Access

  • Enhance efficiency and access to care and services.
  • Promote and expand access by ensuring that established patients have round-the-clock access to their care team via phone, email or in-person visits.
  • Provide scheduling options that are patient- and family-centered and accessible to all patients.

Coordinate Care Across the Medical Neighborhood

  • Link patients with community resources to facilitate referrals and respond to social service needs.
  • Integrate behavioral health and specialty care into care delivery through colocation or referral protocols.
  • Track and support patients when they obtain services outside the practice.
  • Follow up with patients within a few days of an ER visit or hospital discharge.
  • Perform medication reconciliation at every office visit and care transition.
  • Communicate test results, care or treatment plans to patients/families.

To support you in your journey towards Medical Home implementation, please join the IHS Quality Portal. In it you will find knowledge, resources and tools to collaborate with IHS, Tribal and Urban Indian facility colleagues working toward similar goals.