September 17, 2019

Framing Our Next Phase of Advanced Primary Care

Partners Population Health Perspectives blog aims to share the opinions and ideas of our leadership team on health care topics related to population health management. In this post, Colleen Blanchette, Corporate Director for Clinical Programs at Partners Population Health, shares her thoughts on the new Partners HealthCare strategy for our work in advanced primary care.

I recently went to Washington, DC to participate in a forum hosted by the Health Care Transformation Task Force (HCTTF), a small working group was comprised of the four “P’s,” providers, payers, purchasers and patient advocates. In this forum – and others – we often share how Partners HealthCare has approached its first phase to implementing an advanced primary care model. These events often leave me energized by simply putting our work into context on the national landscape. Simply put, I am astonished by how far we have come in this work and how much knowledge we have to offer others committed to value-based care.

In 2011, Partners HealthCare committed to implementing a patient-centered medical home (PCMH) delivery model in our primary care practices, with the goal of all primary care physicians practicing in a PCMH. As of 2018, just shy of 100% of practices achieved the National Committee for Quality Assurance (NCQA) recognition. This process enabled the Partners Population Health team to lay the foundational tools, structure and capacity for delivering patient-centered care consistently in our primary care practices. Not only did this work serve as the foundation upon which we could build a patient-centered medical “home” – it provided the infrastructure to deploy innovative care management programs – such as high-risk care management and integrated behavioral health services to all Partners primary care practices and ultimately, patients. Today, our data reinforces the significant value this “home” has offered both patients and providers.

Building Up from a Patient-Centered Foundation

Now we are at an exciting time where we can set a global vision for our health care system for the sustainability and extension of what the patient-centered medical home model will look like, and how we can strive to achieve what we consider to be the best primary care experience for our patients. We selected the areas that represent high quality care for our patients and then reviewed industry metrics that align to those areas.  We narrowed the number of measures to those that best showcased our achievement of those aspirational goals.

The areas of focus include:

  • Expanded Access: Being available when patients need us most.
  • Integrated Care: Seamless care, everywhere, every time.
  • Engaged patients: Engaging patients directly in their care, and meeting more of their needs inside and outside the clinic.
  • Safe, Equitable and High-Quality Care: Keeping patients both healthy and safe.
  • Smarter Spending: Rebalancing resource use toward primary care.
  • Vital Workforce: Understanding and optimizing our workforce’s experience.

These focus areas lend us some exciting challenges to tackle – but first, it requires us to dig deep into our practices to uncover answers to questions, like: What does our same day availability look like? What do our patients experience when they call us on the telephone? How often do patients contact us via the portal?  We only have anecdotal information today but will spend time over the next year collecting this information and will come together as a system to reflect and think about how we can build on areas of success for our patients and expand those consistently across our practices.

This idea of “systemness” is top of mind for advanced primary care, thinking about how primary care practices interface with our entire health care ecosystem. One area we’re trying to improve is our ability to seamlessly do post-discharge outreach and documentation to patients recently discharged from the hospital and emergency department. It’s a vital component to ensuring good primary care, but the assessment and workflow in our electronic health record is not intuitive. Some immediate tasks at hand are mapping out what information should be asked during post discharge outreach, what reporting will be helpful for practices to identify patients in need of a call, and the end-to-end workflow to make it seamless.

If our initial PCMH implementation was all about laying the groundwork, then this next iteration of Advanced Primary Care is all about optimization. Thinking about ways we can tweak and improve technology, quality of care, spending and the work-life balance of our primary care providers means we’re always moving forward. We’re trying to buck the idea that once you’ve reached a goal, that’s good enough—we’re pushing ourselves to evolve. I’m excited that Partners is committed to reaching this next level and elevating the already great work done by our practices.


Colleen Blanchette is Corporate Director for Population Health at Partners HealthCare. In her role, Colleen oversees our suite of clinical care transformation programs including high risk care management (iCMP), behavioral health integration, telehealth, and care continuum, among others. Colleen has been a key contributor to Partners Population Health since its inception, leading one of our cornerstone projects to design, develop and implement the NCQA-recognized Patient-Centered Medical Home (PCMH) model in nearly 100% of Partners primary practices. Additionally, she has helped to drive key system-wide initiatives including training and education for our care teams like the medical assistant certification program, quality improvement initiatives, and risk capture. 

Previously, Colleen has held positions at Partners in contracting, medical management, and account management. Prior to Partners, Colleen worked for the Advisory Board Company in Washington, D.C. Colleen holds a Bachelor of Arts in Neuroscience and Behavior from Mount Holyoke College, a Certificate from UMass Boston for their Emerging Leaders Program, and completed the Advanced Lean training at Virginia Mason Institute.

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