Advanced Primary Care

There are a number of primary care practices across the community who serve a large proportion of complex high needs patients. These individuals frequently have behavioral health and addictions issues that exacerbate their abilities to adhere to recommendations regarding self-care, reliable use of medications, diet, and utilization of health care and other aspects of daily living. While the patient centered primary care home (PCPCH) remains the centerpiece of many aspects of reform, primary care infrastructure frequently lacks a coordinated, proactive approach in the management of complex patients. The goal of the implementation of the Advanced Primary Care (APC) practice model is to develop clinic based multidisciplinary teams with staff skilled to address both medical and non-medical, socio-behavioral complex issues (e.g. behaviorists, pharmacists, outreach workers, care managers and peer mentors) who can assist complex patients in navigating the health system and adhering to treatment plans and improving self-care of their conditions.

Key components of the model include:

  • Patient enrollment based on defined criteria of “high needs” target population and potential for achieving agreed outcome measures
  • Clinic and organizational leadership with program accountability and resources
  • Dedicated clinical APC “team(s)” addressing key medical, behavioral, medication management, and patient support needs
  • Formal care planning processes based on comprehensive assessment of individual needs and preferences,  multidisciplinary reviews, and tracking towards goals
  • Bi-directional service agreements with acute care and specialty, including mental health, addictions and social services, as well as relationships with community resources such as housing.

The phased implementation process is based on what has been learned through previous PCPCH implementations to be the most effective sequence for building effective primary care practice population management:  establishing the key leadership functions and accountabilities, gaining agreement on goals and measures of success, assembling teams capable of meeting the patients’ identified needs, and then creating structured relationships. To accelerate the learning, leaders and staff will be brought together to create consensus on the work of each phase and reconvened as appropriate during a defined implementation period to share lessons learned and best practices. Phases may overlap as the work progresses. In parallel to the development of the delivery system/practice model change, the model will seek to address realignment of payment incentives around agreed upon measurable outcomes or primary care business model changes.


Funders: State Transformation Fund Grant and CMMI Grant.

Current state: Seven clinics are participating in the APC Collaborative including teams from Adventist, Central City Concern, Legacy Emanuel, Legacy Randall Children’s, Multnomah County, OHSU Richmond, and Providence. Clinics have participated in three Learning Sessions to support development of individual programs and share learnings across clinic sites. 

Contact Information: Christine Bernsten,