The purpose of this program is to strengthen primary care and the workforce by establishing fellowship programs to train community-based practicing primary care physician and/or physician assistant champions to lead health care transformation and enhance teaching in community-based settings. Characteristics of transformed health care delivery systems identified by the Centers for Medicare and Medicaid Services (CMS) include:
• Providers across the care continuum participate in integrated or virtually integrated delivery models,
• Care is coordinated across all providers and settings,
• High level of patient engagement and quantifiable results on patient experience,
• Providers leverage the use of health information technology to improve quality,
• Providers perform at the top of their license and board certification,
• Population health measures are integrated into the delivery system, and
• Data are used to drive health system processes.[1]
HRSA also recognizes addressing social determinants of health as a characteristic of transformed health care delivery systems.
[1] CMS State Innovation Models Cooperative Agreement Announcement (May 2014). Available at: http://innovation.cms.gov/Files/x/StateInnovationRdTwoFOA.pdf
