In 2001 the Institute of Medicine (IOM) released the report "Crossing the Quality Chasm: A New Health System for the 21st Century." The report recommended a redesign of the American health care system by providing six "Aims for Improvement": Safety, Effectiveness, Patient-Centeredness, Timeliness, Efficiency, and Equity. These principles set forth a specific direction for policymakers, health care leaders, clinicians, regulators, purchasers, and others to improve the US health care system. Source: IOM-National Academy of Sciences

Now with the passage of the Affordable Care Act (ACA), we are experiencing a significant redesign of the health care system. This redesign and the emerging models are focused on what you may often hear referred to as the "Triple Aim". Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance by 1. improve the health of the population; 2. enhance the patient experience of care (including quality, access, and reliability); and 3. reduce, or at least control, the per capita cost of care. Source: IHI

The following are some of these emerging health care models. Click on the health care model below to get more information including a description and examples of how it connects to 1305 Domain 3 cardiovascular and diabetes strategies and performance measures.

Accountable Care Organization (ACO) (download PDF )

What is an ACO?

An ACO is a local health care organization and a related set of providers (at a minimum, primary care physicians, specialists, and hospitals) that can be held accountable for the cost and quality of care delivered to a defined population.

The goal of the ACO is to deliver coordinated and efficient care. ACOs that achieve quality and cost targets will receive some sort of financial bonus, and under some approaches, those that fail will be subject to a financial penalty. In order to meet the requirements of this type of incentive system, an ACO needs to be able to:

  1. Care for patients across the continuum of care, in different institutional settings
  2. Plan, prospectively, for its budgets and resource needs
  3. Support comprehensive, valid and reliable measurement of its performance (Note this includes reporting on cardiovascular and diabetes measures in line with 1305 Domain 3)
    Source: Robert Wood Johnson Foundation

The federal government is promoting ACOs to pave the way for the shift from our current volume-based reimbursement model to a model based on quality and efficiency. Examples of this include Centers for Medicare & Medicaid Services Shared Savings Program and the Pioneer ACO Model. Both of these ACO programs are required to report on quality performance standards which include NQF 18 Hypertension and NQF 59 Diabetes performance measures. In addition, these ACOs are redesigning their health systems to deliver care that is directly in line with Domain 3 enhanced and optional measures such as implementation of electronic health records, team-based care, patient self-management and medication adherence.

ACOs are expanding throughout the United States. You can learn more about these ACO programs under the National Initiatives Button. You can also explore what States are participating by going to the Center for Medicare & Medicaid Services Innovation Center . There you can search by state for "Where Innovation is Happening".

Community Care Team (download PDF )

The Community Care Team is a multidisciplinary team that partners with primary care offices (specifically Patient Centered Medical Homes), the hospital, and existing health and social service organizations. The goal is to provide patients with the support they need for well-coordinated preventive health services and coordinated linkages to available social and economic support services. States currently implementing the Community Care Team Model have found it a key element in the Patient Centered Medical Home efforts to improve care and reduce avoidable costs, especially those with complex or chronic conditions.

Community Care Teams can be a vital part of your states population health initiatives and support the 1305 cardiovascular and diabetes Domain 3 strategies.

Community Care of North Carolina
Since 1998, North Carolina has been working on an enhanced medical home model called North Carolina Community Care Networks (NCCCN). NCCCN is a public-private partnership between the state and 14 nonprofit Community Care Networks (CCNs).

What makes NCCCN's model unique is that it is a delivery system design that can be effectively adopted in both urban and rural areas, while providing individuals effective, coordinated care. The networks are made up of local providers that deliver significant components of a medical home for low income adults and children enrolled in Medicaid and the State's Children's Health Insurance Program. The program not only connects individuals with providers that are medical homes, but it assures care coordination, disease management, and quality improvement (PCMH functions that small physician practices would find difficult to directly deliver) through a shared CCN staff of care coordinators. Preliminary results suggest that the program has improved the care of patients with chronic conditions and yielded cost savings.

Community Health Worker (download PDF )

A health care model that is gaining increased attention is the community health worker (CHW). It is estimated that there are currently 120,000 CHWs working in the U.S. today in a variety of healthcare settings, communities, and clinical contexts (Rosenthal, 2010).

The most widely accepted definition for CHWs, however, is that of the American Public Health Association, which characterizes CHWs as:

A Community Health Worker (CHW) is a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. This trusting relationship enables the CHW to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.

A CHW also builds individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support and advocacy. (Source: American Public Health Association, 2009).

CHWs may be known by a variety of titles, including community health advisor, lay health worker, community health representative, promotora or promotores de salud, and patient navigators. The actual responsibilities of CHWs vary both within and across these different job titles, but there are several core elements that are common across them. CHWs typically have a strong connection to the patient community they are serving, and are often members of that same community themselves. CHWs are distinguished from other health professionals because their training and orientation focus on education and health system navigation rather than direct provision of health care services. CHWs provide support to the clinical care team by resolving issues that create obstacles to accessing services, such as transportation to appointments, intervention with utility companies, etc. The work of CHWs thus often transcends the medical system, and CHWs may be employed by public health agencies, schools, and other community-based organizations.

The largest federal CHW program began in the late 1960s with the establishment of the Community Health Representative (CHR) program of the Indian Health Service. The CHR program began as a means of directly involving American Indians/Alaskan Indians in their own healthcare by supporting CHRs to work with tribal managers to increase the provision of basic health services in 550 federally recognized American Indian and Alaskan Native communities (Indian Health Service, 2013). The specific job-related tasks of CHRs have evolved over time, but primarily involve disease prevention and health promotion activities, including regular home visits to conduct health assessments and transportation to appointments.

CHW & Hypertension

One study examined the impact of CHWs in promoting medical follow-up in patients with hypertension who lived in low-income neighborhoods in Seattle, WA (Krieger, 1999). CHWs interacted with patients utilizing phone calls, home visits and postcards over a 3-month period. More patients completed a follow-up appointment in the CHW intervention compared to the control (65% vs. 47%, p=.001).

CHW & Diabetes

The impact of CHWs on the prevention and management of diabetes was evaluated in 8 studies. Interventions consisted of individual home visits or group sessions; one study evaluated an intervention that included group education classes, home visits, and a joint provider visit with the CHW at the clinic (Spencer, 2011). Comparators included usual care with access to medical care and educational materials. At least one significant positive outcome favoring the CHW intervention was reported in 6 studies, including significant changes in hemoglobin A1c and improved self-reports of dietary changes. Two studies found no significant differences in HbA1c and other measures (Sixta, 2008; Gary, 2000).

Source: The Institute for Clinical and Economic Review, Community Health Workers: A Review of Program Evolution, Evidence on Effectiveness and Value, and Status of Workforce Development in New England, July 2013

Health Homes (download PDF )

The Affordable Care Act of 2010, Section 2703, created an optional Medicaid State Plan benefit for states to establish Health Homes to coordinate care for people with Medicaid who have chronic conditions by adding Section 1945 of the Social Security Act. CMS expects states health home providers to operate under a "whole-person" philosophy. Health Homes providers will integrate and coordinate all primary, acute, behavioral health, and long-term services and supports to treat the whole person.

Health Homes are for people with Medicaid who:

Have 2 or more chronic conditions
Have one chronic condition and are at risk for a second
Have one serious and persistent mental health condition

Chronic conditions listed in the statute include mental health, substance abuse, asthma, diabetes, heart disease and being overweight. Additional chronic conditions, such as HIV/AIDS, may be considered by CMS for approval.

Health Home Services:

Comprehensive care management
Care coordination
Health promotion
Comprehensive transitional care/follow-up
Patient & family support
Referral to community & social support services

Health Home providers can be:

A designated provider: May be a physician, clinical/group practice, rural health clinic, community health center, community mental health center, home health agency, pediatrician, OB/GYN, or other provider.

A team of health professionals: May include physicians, nurse care coordinators, nutritionists, social workers, behavioral health professionals, and can be free-standing, virtual, hospital-based, or a community mental health center.

A health team: Must include medical specialists, nurses, pharmacists, nutritionists, dieticians, social workers, behavioral health providers, chiropractics, licensed complementary and alternative practitioners.

Reporting Requirements: Health Home service providers must report quality measures to the state. States are also required to report utilization, expenditure and quality data for an interim survey and an independent evaluation.

The Health Home Information Resource Center located on provides useful information to States considering the health home Medicaid State Plan option HHIRC. Technical assistance is available to support state Medicaid agencies in developing and implementing health home programs under Section 2703 of the Affordable Care Act.

For more information, contact: .

Source: Centers for Medicare & Medicaid Services

Patient Centered Medical Home (download PDF )

The Agency for Healthcare Research and Quality (AHRQ) defines a medical home not simply as a place but as a model of the organization of primary care that delivers the core functions of primary health care.

The medical home encompasses five functions and attributes:

1. Comprehensive Care
The primary care medical home is accountable for meeting the large majority of each patient's physical and mental health care needs, including prevention and wellness, acute care, and chronic care. Providing comprehensive care requires a team of care providers. This team might include physicians, advanced practice nurses, physician assistants, nurses, pharmacists, nutritionists, social workers, educators, and care coordinators.

2. Patient-Centered
The primary care medical home provides primary health care that is relationship-based with an orientation toward the whole person. Partnering with patients and their families requires understanding and respecting each patient's unique needs, culture, values, and preferences. The medical home practice actively supports patients in learning to manage and organize their own care at the level the patient chooses.

3. Coordinated Care
The primary care medical home coordinates care across all elements of the broader health care system, including specialty care, hospitals, home health care, and community services and supports. Such coordination is particularly critical during transitions between sites of care, such as when patients are being discharged from the hospital. Medical home practices also excel at building clear and open communication among patients and families, the medical home, and members of the broader care team.

4. Accessible Services
The primary care medical home delivers accessible services with shorter waiting times for urgent needs, enhanced in-person hours, around-the-clock telephone or electronic access to a member of the care team, and alternative methods of communication such as email and telephone care. The medical home practice is responsive to patients' preferences regarding access.

5.Quality and Safety
The primary care medical home demonstrates a commitment to quality and quality improvement by ongoing engagement in activities such as using evidence-based medicine and clinical decision-support tools to guide shared decision making with patients and families, engaging in performance measurement and improvement, measuring and responding to patient experiences and patient satisfaction, and practicing population health management. Sharing robust quality and safety data and improvement activities publicly is also an important marker of a system-level commitment to quality.

For more information visit: The PCMH Resource Center

PCMH Core Clinical Measures include:

NQF 18 - Percentage of members ages 18-85 who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90) during the measurement year.

NQF 59 - The percentage of members 18-75 years of age with diabetes (type 1 and type 2) whose most recent HbA1c level during the measurement year was greater than 9.0% (poor control) or was missing a result, or if an HbA1c test was not done during the measurement year.

The Commonwealth Fund supported the establishment of the Patient-Centered Medical Home Evaluators' Collaborative which brought together over 75 researchers to identify core standardized measures to evaluate the patient centered medical home. In particular, the evaluators agreed that researchers should select measures from each of the following core areas of primary care measurement: preventive care, chronic disease management, acute care, overuse, and safety. The Core Recommended Adult Technical Quality Measures for PCMHs includes NQF 18, NQF 59 as well as additional cardiovascular and diabetes measures such as cholesterol management, tobacco assessment/cessation and cardiac medication adherence.

For more information on PCMH Measures visit: The Commonwealth Fund

Connecting with PCMH in your State:

More than half of the States are implementing Patient Centered Medical Homes. Some examples such as Federally Qualified Health Center Advanced Primary Care Practice, Comprehensive Primary Care Initiative and CMS State Innovation Models Initiative can be found under the National Initiatives Button.

Also consider connecting with your state Primary Care Association or local CMS Quality Improvement Organization (QIO) .

Team-based Care (download PDF )

Team-based health care is defined as the provision of health services to individuals, families, and/or their communities by at least two health providers who work collaboratively with patients and their caregivers - to the extent preferred by each patient - to accomplish shared goals within and across settings to achieve coordinated, high-quality care.

Source: Mitchell et al. 2012. Core principles & values of effective team-based health care

Principles of Team-based Care include:

  • Shared goals
  • Clear roles
  • Mutual trust
  • Effective communication
  • Measurable processes and outcomes

In May 2012 the CDC released the Task Force on Community Preventive Services recommendations for team-based care (TBC) for improving blood pressure control on the basis of strong evidence of effectiveness.

A review of 77 studies of team-based care showed that patients' control of blood pressure improved when their care was provided by a team of health professionals - a primary care provider supported by a pharmacist, nurse, dietitian, social worker, or community health worker - rather than by a single physician.

The collected studies showed that team-based care helped increase the proportion of patients with controlled blood pressure, led to a decrease in both systolic and diastolic blood pressure, and improved outcomes in patients who had diabetes and elevated blood lipids.

"Adoption of this model throughout the United States would improve blood pressure control for the 68 million American adults who have high blood pressure and reduce their risk of heart attack, stroke, and other health problems," said Thomas R. Frieden, M.D., M.P.H., director, Centers for Disease Control and Prevention.
Source: CDC Task Force Recommends Team-Based Care for Improving Blood Pressure Control Developed by CDC's Division for Heart Disease and Stroke in collaboration with Prevention The Community Guide

To learn more about the Summary of Task Force Recommendations and Findings visit:
The Community Guide

Broader than the Health Care Practice: When we think of team-based care, we think of a wider view to include everyone involved in the patient's care. This may include specialists, dentist, the optometrist, orthopedic surgeon, allergist, surgeon, cardiologist, and endocrinologist. But you have to think beyond this to others like the pharmacists, those involved in home care, visiting nurses, community health workers, mental health specialist, physical and occupational therapists, health educators, dietician, diabetes educator and of course public health partners including state cardiovascular and diabetes programs.

Examples of Team-based Care in Blood Pressure Management

Pharmacists - Managing blood pressure and/or diabetes medications can be challenging. CDC's Diabetes Prevention and Control Program (DPCP) and Heart Disease and Stroke Prevention (HDSP) Programs both include a focus on enhancing the role of community pharmacists in team-based care.

Pharmacists are an integral part of patient care and should be encouraged to work closely with physicians and the healthcare team to help patients meet treatment goals.

Pharmacist's role can include:

  • Address any concerns about medications (including cost, organizing pill boxes, side effects, and why medicine was prescribed)
  • Review any home monitoring or test results, such as blood pressure or blood sugar
  • Show patients how to refill prescriptions more easily
  • Make sure home monitoring devices are working properly and go over how to use them
  • Help patients create a list of medications and keep it up-to-date
  • Help patients identify concerns or questions, such as working with patient's doctor to change medication or order additional tests

The CDC has developed a Program Guide for Public Health - Partnering with Pharmacists in the Prevention and Control of Chronic Diseases. This guide provides definitions, in depth description of the role of pharmacists, pharmacist scope of practice policies and strategies for partnering with local pharmacists in your state. The guide also provides examples of evidence-based programs such as the Asheville Project and the Diabetes 10-City Challenge.
You can download the complete PDF report here

Another resource is the CDC's Team Up. Pressure Down nationwide program in partnership with the Million Hearts® initiative, to lower blood pressure and prevent hypertension through pharmacist-patient engagement. Visit: Million Hearts