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/Jennie%20Chin%20Hansen%20cropped-1.jpg

    Aging expert calls for 'all hands on deck' to meet seniors' care needs

    April 19, 2016

    Recognizing that there will be too few geriatricians to meet the needs of our growing senior population, the medical community needs to train and make use of the talents all those who come into contact with seniors, including family caregivers and non-medical professionals, said renowned geriatrics expert Jennie Chin Hansen.

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    Care managers get training in crisis response

    April 15, 2016

    To address upticks in mental health visits and a dramatic increase in heroin overdoses, FLHSA is offering Mental Health First Aid Training to care managers in its practice transformation initiative. The free two-day course prepares clinicians to “recognize the signs, symptoms and risk factors” for mental illness, said trainer Jay Roscup, grants administrator for Eastern Wayne County schools.

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    Care management gives patient 'new life'

    October 05, 2015

    Ronald Secor was so compromised from pulmonary fibrosis he was slowly suffocating. Then he started working with Kathleen Hoven, a new type of medical professional called a care manager.

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    Patient support leads to 'phenomenal' results

    October 05, 2015

    So much of medicine in the last century has been focused on technological miracles. But as this video reveals, treating many of today’s chronic illnesses calls for old fashioned human caring and professional support.

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    FLHSA to co-lead $48.5 million award

    September 30, 2015

    Finger Lakes Health Systems Agency and the New York eHealth Collaborative have been awarded $48.5 million over four years to help medical practices in our region and around the state transition to team-based, data-informed care.