Since the fall of 2016, CHMG practices dedicate two to four hours per month to focus on practice improvements that included: § Defining the roles of each staff position; § Pre-visit planning by the team members; § Implementing daily huddles within the team to enhance communication and prepare for patient care schedules; § Warm handoffs, in which a medical provider introduces patients to a behavioral health specialist located at the primary care practices; § Expansion of additional ancillary services, including physical therapy, dietary consultation and diabetes education; § Continued expansion of the Medical Home Nurse Navigation program to identify higher-risk patients that need case management and to expand communication to family members. Nurse navigators work with patients, families, caregivers, healthcare teams and community partners to help patients manage chronic illness or disease, understand treatment options and engage in wellness efforts. The training has led to meaningful results, including helping practices improve patient flow and communication.The training and continuing team meetings allowed time for all levels of staff to participate in defining the roles of clinical and clerical support roles.This effort is allowing all licensed providers to work to the fullest potential as a physician, nurse practitioner, physician assistant or nurse. CHMG practices now have patient care coordinators who answer phones and schedule patients, filtering calls that don’t need to go to a nurse or medical assistant, but making sure callers who do need prompt attention receive it. CHMG practices are implementing the team-based model by sharing information about what is working and not working with other practices to standardize some processes. “Atthemeetings,everyonehasthesamevoice.We’reallequalplayers. Whenwecomeupwithanewideaoraproblemweneedtosolve,insteadof managementsaying‘Thisishowwearegoingtodoit,’weallworktogether.” ~JodiSchroeder,APRN,ConcordHospitalMedicalGroupEpsomFamilyMedicine C O N C O R D H O S P I T A L A N N U A L R E P O R T 2 0 1 7 21