Our experiences studying exemplar primary care practices, and our work assisting other practices to become more patient centered, led to a formulation of the essential elements of primary care, which we call the 10 building blocks of highperforming primary care. The building blocks include 4 foundational elementsengaged leadership, data-driven improvement, empanelment, and team-based care-that assist the implementation of the other 6 building blocks-patient-team partnership, population management, continuity of care, prompt access to care, comprehensiveness and care coordination, and a template of the future. The building blocks, which represent a synthesis of the innovative thinking that is transforming primary care in the United States, are both a description of existing high-performing practices and a model for improvement. 2014;166-171. doi: 10.1370/afm.1616. Ann Fam Med INTRODUCTIONA chieving the triple aim of health reform-better health, improved patient experience, and more affordable costs-is dependent on a foundation of high-performing primary care. To this end, a vigorous movement is underway to re-engineer primary care practices. Both patients and care providers feel uncertain about how this new primary care model looks. Practices could benefit from a roadmap to help navigate the journey from old to new. In this article we describe a conceptual model that guides our work as practice improvement facilitators: the 10 building blocks of high-performing primary care. The model represents the synthesis of our thinking from a decade of observing and experiencing improvement work in primary care. METHODSOur development of the building blocks framework was based on case study methods using information from several sources: site visits by the authors and colleagues to 23 highly regarded practices, 1,2 our experiences as practice facilitators in more than 25 practices, and a review of existing models and research on primary care improvement. Seven site visits were performed by the authors; for the others, the authors reviewed site visit reports, looking for descriptions of building block implementation.Practices were selected for site visits on the basis of being known as innovators and having a reputation for high performance in 1 or more of the triple aims. The 23 practices included 8 hospital-based clinics, 7 integrated delivery system sites, 6 federally qualified health centers, and 2 independent private practices. Seven of the 23 practices had 5 or fewer physicians.2 Most of the 25 practices for which the authors have worked as practice facilitators are federally qualified health centers.From these case studies and coaching experiences, we used an iterative process to identify common attributes of high-performing primary care. By comparing and discussing field notes, we discerned a set of elementsbuilding blocks-that occurred with regularity among well-functioning practices. We cross-referenced emerging building block concepts with themes articulated in other published frameworks to look for shared...

PURPOSE Peer health coaches offer a potential model for extending the capacity of primary care practices to provide self-management support for patients with diabetes. We conducted a randomized controlled trial to test whether clinic-based peer health coaching, compared with usual care, improves glycemic control for low-income patients who have poorly controlled diabetes. METHODWe undertook a randomized controlled trial enrolling patients from 6 public health clinics in San Francisco. Twenty-three patients with a glycated hemoglobin (HbA 1C ) level of less than 8.5%, who completed a 36-hour health coach training class, acted as peer coaches. Patients from the same clinics with HbA 1C levels of 8.0% or more were recruited and randomized to receive health coaching (n = 148) or usual care (n = 151). The primary outcome was the difference in change in HbA 1C levels at 6 months. Secondary outcomes were proportion of patients with a decrease in HbA 1C level of 1.0% or more and proportion of patients with an HbA 1C level of less than 7.5% at 6 months. Data were analyzed using a linear mixed model with and without adjustment for differences in baseline variables.RESULTS At 6 months, HbA 1C levels had decreased by 1.07% in the coached group and 0.3% in the usual care group, a difference of 0.77% in favor of coaching (P = .01, adjusted). HbA 1C levels decreased 1.0% or more in 49.6% of coached patients vs 31.5% of usual care patients (P = .001, adjusted), and levels at 6 months were less than 7.5% for 22.0% of coached vs 14.9% of usual care patients (P = .04, adjusted).CONCLUSIONS Peer health coaching signifi cantly improved diabetes control in this group of low-income primary care patients. Ann Fam Med 2013;11:137-144. doi:10.1370/afm.1443. INTRODUCTIONP rimary care faces serious challenges in the face of the growing demand for diabetes care. Primary care physicians are in short supply and need more time to care for patients with highly complex conditions whose costs are destabilizing US health care.1 Current numbers of nurse practitioners and physician assistants are not suffi cient to provide access to the increasing demand for primary care.1,2 Registered nurses and pharmacists, who are capable of managing a large proportion of patients with diabetes, are too costly for many primary care practices. The time of medical assistants is often consumed by managing patient fl ow and assisting clinicians to get through the day. 3 In sum, many primary care practices have no one available to provide the time-consuming counseling and teaching of self-management skills that have been shown to improve diabetes outcomes. 4 To address this need, several models have been developed to provide support for patient self-management from lay workers with minimal 138 PEER HE A LT H COACHING A ND G LYC EMIC CON T ROLtraining, including community health workers, lay peer educators, and peer coaches. Community health workers are from the community of the patients they assist but do not necessarily have the same disease as the patient. ...

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