Practice Transformation

Our Programs

Transformation Clinical Practice Initiative

Under this Centers for Medicare & Medicaid Services (CMS) initiative, Common Ground Health has partnered with New York eHealth Collaborative to form the New York State Practice Transformation Network. The peer-based learning network mentors primary and specialty care clinicians in the core competencies* necessary for continuous quality improvement. The initiative also helps to connect practices with national experts and the network of 140,000 providers across the country who are participating in CMS efforts to improve the health care system.

New York State Advanced Primary Care Model

The NYS Advanced Primary Care initiative is designed to help primary care and pediatric practices shift towards value-based care – new payment structures based on outcomes not procedures. As part of New York state’s ongoing work to transform healthcare delivery, the program provides no-cost, one-on-one consulting to help practices develop core competencies, such as team-based methods and care management. Such advanced methods have been shown to improve patient outcomes and satisfaction and to lower costs. Following a practice assessment, a customized work plan is developed in collaboration with the practice team to improve workflow and achieve program milestones.

Educational training

Through webinars, online resources and curriculum development, our technical assistance team are helping practices locally and across the state develop skills and adopt approaches that can lead to improved team-based work flows that focus on better patient outcomes.

Support for value-based health care

The transition from fee-for-service to value-based care requires providers to truly embrace the quadruple aim of engaging patients, improving outcomes, increasing value and enhancing the joy in practice. Common Ground Heath’s programs provide coaching and tools for meeting the evolving reimbursement metrics.

To find out more about Common Grounds Health’s Practice Transformation programs, contact William Brien  at or (585)224-3149

*Core Competencies

Population health

Proactively promote health through prevention, chronic disease management and promotion of a healthy and safe environment. For example, providers can encourage older patients to have their recommended screenings for colon and breast cancer.

Care management

Coordinate care by actively tracking the sickest patients, collaborating with all of their providers and following patients as they leave the hospital or make other care changes to ensure smooth and safe transitions.

Data to drive improvement

Use electronic medical records to track quality, experience and cost outcomes. For example, practices can use their clinical data to identify and reach out to patients who have uncontrolled high blood pressure before they suffer a stroke, heart attack or other catastrophic cardiac event from the condition.

Access to care

Promote access as defined by affordability, availability, accessibility, and acceptability of care across all patient populations


Create a work culture in which everyone on staff works as a team to meet goals. Practices learn to use team approaches such as the “morning huddle”—daily all staff meetings to review who is scheduled for the day and what special needs they may have.

Patient-centered care

Engage patients as active, informed participants in their own care, through such approaches as motivational interviewing.


Initiatives - Advaned Primary Care - Articles Featured

Initiatives - Advaned Primary Care - Articles

  • ~/Media/Default/Article/Image/TriCounty-2-1.jpg

    New procedures helped rural practice improve

    May 30, 2019

    By putting in place relatively simple new procedures, Tri-County Family Medicine Program, Inc., achieved a 5-percentage point decline in patients with uncontrolled diabetes, among other improvements.

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    Gates Medical's high blood pressure success lies in ...

    April 30, 2019

    Common Ground's high blood pressure registry shows that Gates Medical Associates has achieved unusually good control rates for groups that are at high risk for poor hypertension outcomes. Find out what makes the University of Rochester practice so effective.

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    Health center achieves patient-centered milestone

    January 28, 2019

    Over the past three years, His Branches in Rochester reduced wait times for patients, improved patient outcomes and created a work environment that was less stressful. Together these changes helped the safety net practice renew its Patient-Centered Medical Home (PCMH) certification through the New York PCMH program, which began in 2018.

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    Doctor's orders? More like, patient's preferences

    December 18, 2018

    Motivational interviewing puts patients in the driver's seat on behavior change. Common Ground has helped coach clinicians on using motivational interviewing as part of practice transformation.

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    How clinical data and coaching are driving improvement in high blood pressure

    August 23, 2018

     It’s one thing for medical practices to push for better blood pressure rates among patients. It’s another for them to see—with colorful numbers, charts and graphs—whether their efforts are making a difference.

     And in large part because of the High Blood Pressure Registry, they are.

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    Eight reasons to stay focused on high blood pressure

    June 27, 2018

    The latest high blood pressure registry along with other local data show that high blood pressure and heart disease are leading drivers of premature mortality in our nine county Finger Lakes region, particularly for African Americans. View all eight data slides showing why we should stay focused on this chronic illness.

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    Succeed in the new world of value-based payments

    May 22, 2017

    From MACRA and MIPS to SIM and SHIP, federal and state programs have made the primary care landscape more complex than ever before. That’s where our expert consultants can help. Common Ground Health can provide no-cost assistance to practices looking to participate in the state’s Advanced Primary Care model or prepare for new quality reporting requirements.

  • ~/Media/Default/Article/Image/colonoscopy%20880w390h-1.jpg

    The Finger Lakes region embraces primary care 2.0

    July 13, 2016

    For the past four years, sixty five primary care practices—about a third of the region’s primary care providers—have partnered with Finger Lakes Health Systems Agency on an uncharted journey to make our medical system as good at preventing medical emergencies as it is at treating them. The $26.6 million experiment in primary care innovation is showing how teamwork and smart data can improve patient care and reduce costs.

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    Network offers medical practices a running start on new value-based payments

    June 14, 2016

    To get ahead of a shift from volume to value-based payments for medical services, Finger Lakes Health Systems Agency and the New York eHealth Collaborative are recruiting primary care, pediatrics and specialty care providers to take part in New York State’s new Practice Transformation Network.