Statewide Healthcare Innovation Plan (SHIP)
“The mission of the Southeastern Healthcare Collaborative (SHC) is to support Primary Care medical practices in their transition to and maintenance of Patient Centered Medical Homes (PCMHs) and to support the integration of each PCMH with the Medical Health Neighborhood. This will be accomplished by providing a structured forum for sharing valuable knowledge, finding common solutions, identifying resources to achieve improved health outcomes, improved quality and patient experience of care, and lower costs for all Idahoans.”
The Idaho Statewide Healthcare Innovation Plan (SHIP) will redesign Idaho’s healthcare system to:
- Improve Idahoans’ health by strengthening primary and preventive care through the patient centered medical home, and,
- Evolve from a fee–for-service, volume-based payment system of care to a value-based payment system that rewards improved health outcomes.
PCMH & NCQA Documents
- AAAHC, NCQA Crosswalk
- Medical Health Neighborhood
- NCQA
- 1. Team Based Care
- TC Policies & Examples
- TC01 Policy
- TC01, TC02, and TC06 example
- TC02 Policy
- TC02- In depth description of staff roles skills and responsibilities
- TC04 Patient Involvement
- TC06 Huddle form (Lost Rivers)
- TC06 Pre-visit planning immunization checklist
- TC06 Team Meetings
- TC07 Care Team Involvement
- TC07 Clinic policy example
- TC07 Quality and Risk Management Plan
- TC08 Behavioral Health Champion
- TC09 Role of the Medical Home
- TC09, AC11 Policy Example
- TC Tools & Resources
- Team-Step3-Share the Care Worksheet-assess team roles and tasks
- Adminstration Huddle Template
- Care Team Roles and Responsibilities Activity
- Example of traditional practice versus team
- FOCUS, GOALS AND WORKFLOW FOR EXTENDED CARE TEAM- DRAFT
- Huddle Practice Survey Questions
- Practice example of Admin. Huddle
- Script - Patient Intro to PCMH
- 2. Knowing and Managing Your Patients
- KM Policies & Examples
- KM04 Behavioral Health Screening
- KM05 Oral Health Asssessment Tool for Primary Care
- KM06 Example
- KM12 1305 Hypertension Postcards
- KM12 Adult immunizations
- KM12 Diabetes letter
- KM12 disasters parent flu letter
- KM12 Ex. reminder to schedule mammogram letter
- KM12 Immunization Reminder Letter
- KM12 Patient-Care-Reminders-population health action planning
- KM20 Evidence Based Guidelines
- KM21 Patient Resource Needs Survey
- KM21 Policy
- KM Tools & Resources
- KM02 Screen and Intervene
- KM02 Social Determinants of Health example
- Oral Health Coding Fact Sheet for Primary Care Physicians
- KM05 Use of oral health risk assessment in primary care
- KM11 Health Literacy - Hidden Barriers Practical Strategies
- KM11 Health Literacy Resources
- 3. Patient Centered Access and Continuity
- AC Policies & Examples
- AC01 Policy
- AC02 Policy
- AC02, 03, 04 Policy
- AC04 Policy
- AC04, AC05 Policy
- 4. Care Management
- 5. Care Coordination and Care Transitions
- CC Policies & Examples
- CC01 Imaging algorithm
- CC01 Lab algorithm
- CC01 Policy
- CC04 Documented Process
- CC04 Referral algorithm
- CC08 Collaborative Care Compact
- Primary Care – Specialist Physician Collaborative Guidelines
- CC14, 15, 16 Policy Example 1
- CC14, 15,16 Policy example 2
- CC Tools & Resources
- Emergency Department follow up script
- 6. Performance Management and Quality Improvement - Policies & Examples
- QI01 Practice and Provider Dashboard Example
- QI01, 02 Process Example
- QI01, 08, 12 (Hypertension,example with SIPH in blood pressure cuff program)
- QI01, 08, 12 (QI Qualis Pneumo Vax Example)
- QI02 Examples
- QI02 Healthcare cost generic rx example
- QI02 LightBeam Savings
- QI03 3rd NAA tracking
- QI03 Documented Process for 3rd NAA tracking Example
- QI04 Paitent Comment Cards Example
- QI04 Patient Satisfaction Survey Example1
- QI04 Patient Satisfaction Survey Example2
- QI15 Quality Board Example 2
- QI15 Quality Board Example 1
- QI15 Quality Measure Dashboard Example
- 1. Team Based Care
- Getting started, tips for success
- Policy Writing Tips
- Submitted Questions to NCQA
- PCMH Learning Activities
- PCMH Presentations
Regional solutions for regional environments!
While testing a statewide model of healthcare delivery transformation, Idaho is relying on primary care providers to practice patient-centered and effectively coordinated care. This coordination of care is impossible without mobilizing the complete medical/health neighborhood in which patient resides - specialists, hospitals, behavioral health professionals, long term care providers, pharmacists, social service agencies and community based organizations, just to name a few. At the local level, Idaho’s seven Public Health Districts will serve as the main facilitators of the regional effort to address goals and objectives enumerated by the SHIP. They will assist and support primary care practices (PCPs) in the transformation to become patient-centered medical homes (PCMH), convene and support Regional Health Collaboratives and work with the stakeholders to organize and advance greater connection between medical/health neighbors in the region.
Regional Collaboratives
The Regional Collaboratives (RC) will facilitate development of the medical neighborhoods to strengthen patient care coordination and will convene a regional stakeholder advisory collaborative group. The RC stakeholder advisory collaborative group will have direct input to the IHC through the PHD directors and RC collaborative chairs, so regional and local concerns can be raised at the state level. In the management of RCs, Idaho’s PHDs will lead integration of public health and population management into the model, and will bring an intimate familiarity with local healthcare resources to developing the medical neighborhood. Communities will participate in community needs assessments and will work with the RCs to align specific performance metrics for the PCMHs in their region with identified areas of need.
Program Goals
Goal 1: Transform primary care practices across the state into patient-centered medical homes (PCMHs).
Idaho will test the effective integration of PCMHs into the larger healthcare delivery system by establishing them as the vehicle for delivery of primary care services and the foundation of the state’s healthcare system. The PCMH will focus on preventive care, keeping patients healthy and stabilizing patients with chronic conditions. Grant funding will be used to provide training, technical assistance and coaching to assist practices in this transformation.
Goal 2: Improve care coordination through the use of electronic health records (EHRs) and health data connections among PCMHs and across the medical neighborhood.
Idaho’s proposal includes significant investment in connecting PCMHs to the Idaho Health Data Exchange (IHDE) and enhancing care coordination through improved sharing of patient information between providers.
Goal 3: Establish seven Regional Collaboratives to support the integration of each PCMH with the broader medical neighborhood.
At the local level, Idaho’s seven public health districts will convene Regional Collaboratives that will support provider practices as they transform to PCMHs.
Goal 4: Improve rural patient access to PCMHs by developing virtual PCMHs.
This goal includes training community health workers and integrating telehealth services into rural and frontier practices. The virtual PCMH model is a unique approach to developing PCMHs in rural, medically underserved communities.
Goal 5: Build a statewide data analytics system that tracks progress on selected quality measures at the individual patient level, regional level and statewide.
Grant funds will support development of a state-wide data analytics system to track, analyze and report feedback to providers and regional collaborative(s). At the state level, data analysis will inform policy development and program monitoring for the entire healthcare system transformation.
Goal 6: Align payment mechanisms across payers to transform payment methodology from volume to value.
Idaho’s three largest commercial insurers, Blue Cross of Idaho, Regence and PacificSource, along with Medicaid will participate in the model test. Payers have agreed to evolve their payment model from paying for volume of services to paying for improved health outcomes.
Goal 7: Reduce overall healthcare costs.
Financial analysis conducted by outside actuaries indicates that Idaho’s healthcare system costs will be reduced by $89M over three years through new public and private payment methodologies that incentivize providers to focus on appropriateness of services, improved quality of care and outcomes rather than volume of service. Idaho projects a return on investment for all populations of 197% over five years.
Southeastern Healthcare Collaborative Chair
Dr. Mark Horrocks
Chief Medical Officer
Health West Inc.

Southeastern Healthcare Collaborative Co-Chair
Dr. Christopher Heatherton
Bingham Memorial Hospital

Maggie Mann
District Director
Southeastern Idaho Public Health
1901 Alvin Ricken Dr.
Pocatello, ID 83201

Tracy McCulloch
Community Health Director
Southeastern Idaho Public Health
1901 Alvin Ricken Dr.
Pocatello, ID 83201

Allison Palmer, CHES, PCMH CCE
SHIP QI/QA Specialist
Southeastern Idaho Public Health
1901 Alvin Ricken Dr.
Pocatello, ID 83201
(208) 239-5218

Effie Jones
SHIP Administrative Assistant
Southeastern Idaho Public Health
1901 Alvin Ricken Dr.
Pocatello, ID 83201
(208) 239-5212

Rhonda D’Amico, MHE
Statewide Healthcare Innovation Program (SHIP) Program Manager
Southeastern Idaho Public Health
1901 Alvin Ricken Dr.
Pocatello, ID 83201
(208) 239-5227