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Physician 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:
- Coordination of care*
- Evidence-based care tracking to reduce gaps in care
- Extended access*
- Individual care management*
- Lean clinical reengineering CQI
- Linkage to community services*
- Patient-provider partnership*
- Performance reporting*
- Preventive services*
- Self-management support*
- Specialist referral process*
- Test tracking and follow-up*
- Transitions of care - Michigan Transition of Care Collaborative (M-TC2)
* These initiatives relate to Patient-Centered Medical Home.
