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Learn morePhysician Group Incentive Program (PGIP)
Core clinical process-focused initiatives
Linkage to community services — (PCMH)
PGIP Ref#: CCP-09-11
BCBSM Administrative Lead: Margaret Mason
Description: In this initiative, patients will be linked to outside resources through a process of active coordination between the patient, family, caregivers, community service agencies, and health system.
Fact Sheet: Linkage to Community Services PC-MH Initiative (PDF)
Other core clinical process-focused initiatives:
- Evidence-based care tracking to reduce gaps in care
- Performance reporting*
- Patient-provider partnership*
- Extended access*
- Individual care management*
- Test tracking and follow-up*
- Lean clinical reengineering for PCMH CQI
- Coordination of care*
- Preventive services*
- Specialist referral process*
- Self-management support
- Transitions of care
* These initiatives relate to Patient-Centered Medical Home.
