Evidence-based health and well-being for entire populations.

Care Transformation Collaboration

The Transforming Clinical Practice Initiative (TCPI), an 8.3 million dollar grant awarded to RIQI through CMS, is a new opportunity for clinicians to improve patient outcomes and quality of care while preparing for the inevitable financial changes and future reimbursement models that are rapidly unfolding and directly tied to quality. TCPI has partnered with Pro-Change to make evidence-based award-winning behavior change tools available to both patients and clinicians at five practices throughout the state.

As part of the newly released HealthCoach for Me, patients are invited to complete a brief online self-assessment in the waiting or exam room to determine their risks. When they meet with a clinician, she or he has immediate access to actionable insights, based on the patient’s readiness to change, via a clinical dashboard. The dashboard displays the patient’s risks and stage of change for each risk and enables the clinician to deliver a brief, tailored behavior change message matched to the patient’s stage of change for that behavior. Clinicians can then prescribe the online Tobacco Cessation, Weight Management, Healthy Eating, or Exercise programs the patient can do at home. When patients return for follow-up visits, their stage of change can quickly be re-assessed, enabling the clinician to reinforce any progress, address any challenges, and deliver updated tailored behavior change guidance.

The pilot will continue through at least the end of 2018.