1. The Colorado Family Medicine Residency PCMH Project North Colorado Family Medicine, Greeley, CO Sarah DeMoor, MD, Emily Lieder, DO, Paul Lobitz, MD (and their fabulous teammates!)

2. The Colorado Family Medicine Residency PCMH Project Our biggest innovation/accomplishment so far in our PCMH effort 1.PCP and Team Continuity 2.Improved documenting and Care Management of our CICs 3.Integrated Behavioral Health 4.Working as a “team”, better “practice management” 5.Understanding the pros/cons of different EMRs for good data and patient management

3. The Colorado Family Medicine Residency PCMH Project Other important changes we have made since the last Collaborative 1.Same Day Appointments/Access 2.Care Management integration for improving follow-up, patient education 3.Registry implementation and now starting to manage aggressively 4.Monthly “Team Meetings” clinic wide 5.Improved clinic wide communication

4. The Colorado Family Medicine Residency PCMH Project Our practice’s top goals for this year related to PCMH 1.Expanded Care Management and registry management for o Diabetes o Depression o Childhood Obesity o Outstanding diagnostics o Referrals 2.Patient Web Portal 3.Integrated Behavioral Health with outside agency using our clinic for our patients for better continuity

5. The Colorado Family Medicine Residency PCMH Project Our practice’s top goals for this year related to PCMH 4.Advanced Access Scheduling 5.Continued work on continuity both inpatient and outpatient 6.Revisit core CICs and audit 7.Implement Chronic Pain as new CIC