4.b.ii- Increase Access to High Quality Chronic Disease Preventative Care and Management in both Clinical and Community Settings

  • Improve incentives for prevention services such as cancer screenings


Care coordination / patient navigation / population health

  • Offer recommended clinical preventive services and connect patients to community-based preventive service resources
  • Adopt and use certified electronic health records, especially those with clinical decision supports and registry functionality 
  • Send reminders to patients for preventive and follow-up care, and identify community resources available to patients to support disease self-management
  • Adopt medical home or team-based care models

Community support

  • Incorporate Prevention Agenda goals and objectives into hospital Community Service Plans, and coordinate implementation with local health departments and other community partners
  • Create linkages with and connect patients to community preventive resources

Integration of care / IDS

Provide feedback to clinicians around clinical benchmarks and incentivize quality improvement efforts

Payment reform

  • Establish or enhance reimbursement and incentive models to increase delivery of high-quality chronic disease prevention and management services
  • Reduce or eliminate out-of-pocket costs for clinical and community preventive services

PMO Project Representatives:

Shannon McWilliam- mcwills1@mail.amc.edu



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