Improving Quality Improvement Capacity and Clinical Performance in Small Primary Care Practices.

PURPOSE: We undertook a study to assess whether implementing 7 evidence-based strategies to build improvement capacity within smaller primary care practices was associated with changes in performance on clinical quality measures (CQMs) for cardiovascular disease. METHODS: A total of 209 practices across Washington, Oregon, and Idaho participated in a pragmatic clinical trial that focused on building quality improvement capacity as measured by a validated questionnaire, the 12-point Quality Improvement Capacity Assessment (QICA). Clinics reported performance on 3 cardiovascular CQMs-appropriate aspirin use, blood pressure (BP) control (<140/90 mm Hg), and smoking screening/cessation counseling-at baseline (2015) and follow-up (2017). Regression analyses with change in CQM as the dependent variable allowed for clustering by practice facilitator and adjusted for baseline CQM performance. RESULTS: Practices improved QICA scores by 1.44 points (95% CI, 1.20-1.68; P <.001) from an average baseline of 6.45. All 3 CQMs also improved: aspirin use by 3.98% (average baseline = 66.8%; 95% CI for change, 1.17%-6.79%; P = .006); BP control by 3.36% (average baseline = 61.5%; 95% CI for change, 1.44%-5.27%; P = .001); and tobacco screening/cessation counseling by 7.49% (average baseline = 73.8%; 95% CI for change, 4.21%-10.77%; P <.001). Each 1-point increase in QICA score was associated with a 1.25% (95% CI, 0.41%-2.09%, P = .003) improvement in BP control; the estimated likelihood of reaching a 70% BP control performance goal was 1.24 times higher (95% CI, 1.09-1.40; P <.001) for each 1-point increase in QICA. CONCLUSION: Improvements in clinic-level performance on BP control may be attributed to implementation of 7 evidence-based strategies to build quality improvement capacity. These strategies were feasible to implement in small practices over 15 months.

The role of organizational learning and resilience for change in building quality improvement capacity in primary care.

BACKGROUND: The extent that organizational learning and resilience for the change process, that is, adaptive reserve (AR), is a component of building practice capacity for continuous quality improvement (QI) is unknown. PURPOSE: The aim of the study was to examine the association of AR and development of QI capacity. METHODOLOGY: One hundred forty-two primary care practices were evaluated at baseline and 12 months in a randomized trial to improve care quality. Practice AR was measured by staff survey along with a validated QI capacity assessment (QICA). We assessed the association of baseline QICA with baseline AR and both baseline and change in AR with change in QICA from 0 to 12 months. Effect modification by presence of QI infrastructure in parent organizations and trial arm was examined. RESULTS: Mean QICA increased from 6.5 to 8.1 (p < .001), and mean AR increased from 71.8 to 73.9 points (p < .001). At baseline, there was a significant association between AR and QICA scores: The QICA averaged 0.34 points higher (95% CI [0.04, 0.64], p = .03) per 10-point difference in AR. There was a significant association between baseline AR and 12-month QICA-which averaged 0.30 points higher (95% CI [0.02, 0.57], p = .04) per 10 points in baseline AR. There was no association between changes in AR and the QICA from 0 to 12 months and no effect modification by trial arm or external QI infrastructure. CONCLUSIONS: Baseline AR was positively associated with both baseline and follow-up QI capacity, but there was no association between change in AR and change in the QICA, suggesting AR may be a precondition to growth in QI capacity. PRACTICE IMPLICATIONS: Findings suggest that developing AR may be a valuable step prior to undertaking QI-oriented growth, with implications for sequencing of development strategies, including added gain in QI capacity development from building AR prior to engaging in transformation efforts.

Leading Innovative Practice: Leadership Attributes in LEAP Practices.

Policy Points An onslaught of policies from the federal government, states, the insurance industry, and professional organizations continually requires primary care practices to make substantial changes; however, ineffective leadership at the practice level can impede the dissemination and scale-up of these policies. The inability of primary care practice leadership to respond to ongoing policy demands has resulted in moral distress and clinician burnout. Investments are needed to develop interventions and educational opportunities that target a broad array of leadership attributes. CONTEXT: Over the past several decades, health care in the United States has undergone substantial and rapid change. At the heart of this change is an assumption that a more robust primary care infrastructure helps achieve the quadruple aim of improved care, better patient experience, reduced cost, and improved work life of health care providers. Practice-level leadership is essential to succeed in this rapidly changing environment. Complex adaptive systems theory offers a lens for understanding important leadership attributes. METHODS: A review of the literature on leadership from a complex adaptive system perspective identified nine leadership attributes hypothesized to support practice change: motivating others to engage in change, managing abuse of power and social influence, assuring psychological safety, enhancing communication and information sharing, generating a learning organization, instilling a collective mind, cultivating teamwork, fostering emergent leaders, and encouraging boundary spanning. Through a secondary qualitative analysis, we applied these attributes to nine practices ranking high on both a practice learning and leadership scale from the Learning from Effective Ambulatory Practice (LEAP) project to see if and how these attributes manifest in high-performing innovative practices. FINDINGS: We found all nine attributes identified from the literature were evident and seemed important during a time of change and innovation. We identified two additional attributes-anticipating the future and developing formal processes-that we found to be important. Complexity science suggests a hypothesized developmental model in which some attributes are foundational and necessary for the emergence of others. CONCLUSIONS: Successful primary care practices exhibit a diversity of strong local leadership attributes. To meet the realities of a rapidly changing health care environment, training of current and future primary care leaders needs to be more comprehensive and move beyond motivating others and developing effective teams.

Engaging patients in primary care design: An evaluation of a novel approach to codesigning care.

OBJECTIVE: Recognition is growing that to create truly patient-centred care, health-care organizations need to partner with patients around care design. More research into the benefits of engaging patients and the most effective ways of partnering with them is needed. METHODS: This study assessed the process and impact of a collaborative effort to design a new clinic service that balanced the number of patient and clinical provider/staff codesigners involved and recruited patients to represent diverse perspectives. Data sources included interviews with participants, event observation and participant surveys. RESULTS: Our evaluation found that including patients as equal partners improved the design process by infusing a real-world, patient perspective. The pre-event orientation and interactive methods used in the event fostered positive collaboration, as well as personal growth for the patient codesigners. CONCLUSION: This study demonstrated the feasibility and benefits of including a roughly equal number of patients and clinical providers/staff in design events and ensuring that the patients represent diverse perspectives.

Assessing quality improvement capacity in primary care practices.

BACKGROUND: Healthy Hearts Northwest (H2N) is a study of external support strategies to build quality improvement (QI) capacity in primary care with a focus on cardiovascular risk factors: appropriate aspirin use, blood pressure control, and tobacco screening/cessation. METHODS: To guide practice facilitator support, experts in practice transformation identified seven domains of QI capacity and mapped items from a previously validated medical home assessment tool to them. A practice facilitator (PF) met with clinicians and staff in each practice to discuss each item on the Quality Improvement Capacity Assessment (QICA) resulting in a practice-level response to each item. We examined the association between the QICA total and sub-scale scores, practice characteristics, a measure of prior experience with managing practice change, and performance on clinical quality measures (CQMs) for the three cardiovascular risk factors. RESULTS: The QICA score was associated with prior experience managing change and moderately associated with two of the three CQMs: aspirin use (r = 0.16, p = 0.049) and blood pressure control (r = 0.18, p = 0.013). Rural practices and those with 2-5 clinicians had lower QICA scores.. CONCLUSIONS: The QICA is useful for assessing QI capacity within a practice and may serve as a guide for both facilitators and primary care practices in efforts to build this capacity and improve measures of clinical quality. TRIAL REGISTRATION: This trial is registered with www.clinicaltrials.gov Identifier# NCT02839382, retrospectively registered on July 21, 2016.

Practice transformation in the safety net medical home initiative: a qualitative look.

BACKGROUND: Transformation of primary care to patient-centered medical homes (PCMH) is challenging. Progress in transformation varied widely among practices involved in the Safety Net Medical Home Initiative. OBJECTIVE: To study 3 successful practices to identify common characteristics and approaches. RESEARCH DESIGN: We selected 3 diverse practices based on their improvement on the PCMH-A, a self-assessment instrument measuring progress toward becoming a PCMH. We interviewed 2-3 leaders from the each of 3 practices seeking information about their motivations for transforming, the methods used to make changes, and challenges and facilitators. Interview data were coded, themes developed, and conclusions drawn using qualitative research methods. RESULTS: For these successful practices, the major motivators were a desire to improve quality of care, patient experience, or provider experience. Financial incentives played a minor role. All practices had engaged, visible leaders driving change, and all ultimately developed an effective quality improvement/practice change strategy that included the provision of trusted performance data at the provider level and an explicit process change strategy. Sequencing the work of PCMH transformation was important, and developing defined provider patient panels and building effective clinical teams facilitated making improvements to access and care delivery. CONCLUSIONS: Practice transformation is disruptive. To be successful, organizations need to have the will or motivation to change, explicit ideas or models on which to base change, and a culture and infrastructure that enables the execution of system changes.

The safety net medical home initiative: transforming care for vulnerable populations.

BACKGROUND: Despite findings that medical homes may reduce or eliminate health care disparities among underserved and minority populations, most previous medical home pilot and demonstration projects have focused on health care delivery systems serving commercially insured patients and Medicare beneficiaries. OBJECTIVES: To develop a replicable approach to support medical home transformation among diverse practices serving vulnerable and underserved populations. DESIGN: Facilitated by a national program team, convening organizations in 5 states provided coaching and learning community support to safety net practices over a 4-year period. To guide transformation, we developed a framework of change concepts aligned with supporting tools including implementation guides, activity checklists, and measurement instruments. SUBJECTS: Sixty-five health centers, homeless clinics, private practices, residency training centers, and other safety net practices in Colorado, Idaho, Massachusetts, Oregon, and Pennsylvania. MEASURES: We evaluated implementation of the change concepts using the Patient-Centered Medical Home-Assessment, and conducted a survey of participating practices to assess perceptions of the impact of the technical assistance. RESULTS: All practices implemented key features of the medical home model, and nearly half (47.6%) implemented the 33 identified key changes to a substantial degree as evidenced by level A Patient-Centered Medical Home-Assessment scores. Two thirds of practices that achieved substantial implementation did so only after participating in the initiative for >2 years. By the end of the initiative, 83.1% of sites achieved external recognition as medical homes. CONCLUSIONS: Despite resource constraints and high-need populations, safety net clinics made considerable progress toward medical home implementation when provided robust, multimodal support over a 4-year period.

Improving care coordination in primary care.

BACKGROUND: Although coordinating care is a defining characteristic of primary care, evidence suggests that both patients and providers perceive failures in communication and care when care is received from multiple sources. OBJECTIVES: To examine the utility of a newly developed Care Coordination Model in improving care coordination among participating practices in the Safety Net Medical Home Initiative (SNMHI). RESEARCH DESIGN: In this paper, we used correlation analysis to evaluate whether application of the elements of the Care Coordination Model by SNMHI sites, as measured by the Key Activities Checklist (KAC), was associated with more effective care coordination as measured by another instrument, the PCMH-A. MEASURES: SNMHI measures are practice self-assessments based on the 8 change concepts that define a PCMH, one of which is Care Coordination. For this study, we correlated 12 KAC items that describe activities felt to improve coordination of care with 5 PCMH-A items that indicate the extent to which a practice has developed the capability to effectively coordinate care. Practice staff indicated whether any of the KAC activities were being test, implemented, sustained, or not on 4 occasions. RESULTS: The Care Coordination Model elements-assume accountability, build relationships with care partners, support patients through the referral or transition process, and create connections to support information exchange-were positively correlated with some PCMH-A care coordination items but not others. Activities related to the model were most strongly correlated with following up patients seen in the Emergency Department or discharged from hospital. CONCLUSIONS: The analysis provides suggestive evidence that activities consistent with the 4 elements of the Care Coordination Model may enable safety net primary care to better coordinate care for its patients, but further study is clearly needed.

Unlocking the black box: supporting practices to become patient-centered medical homes.

BACKGROUND: Despite widespread interest in supporting primary care transformation, few evidence-based strategies for technical assistance exist. The Safety Net Medical Home Initiative (SNMHI) sought to develop a replicable and sustainable model for Patient-centered Medical Home practice transformation. OBJECTIVES: This paper describes the multimodal technical assistance approach used by the SNMHI and the participating practices' assessment of its value and helpfulness in supporting their transformation. RESULTS: Components of the technical assistance framework included: (1) individual site-level coaching provided by local medical home facilitators and supplemented by expert consultation; (2) regional and national learning communities of participating practices that included in-person meetings and field trips; (3) data monitoring and feedback including longitudinal feedback on medical home implementation as measured by the Patient-centered Medical Home-A; (4) written implementation guides, tools, and webinars relating to each of the 8 Change Concepts for Practice Transformation; and (5) small grant funds to support infrastructure and staff development. Overall, practices found the technical assistance helpful and most valued in-person, peer-to-peer-learning opportunities. Practices receiving technical assistance from membership organizations with which they belonged before the SNMHI scored higher on measures of medical home implementation than practices working with organizations with whom they had no prior relationship. CONCLUSIONS: There is an important role for both local and national organizations to provide nonduplicative, mutually reinforcing support for primary care transformation. How (in-person, between-peers) and by whom technical assistance is provided may be important to consider.

Development of a facilitation curriculum to support primary care transformation: the "coach medical home" curriculum.

BACKGROUND: In an effort to improve patient care, retain high-quality primary care providers, and control costs, primary care practices across the United States are transforming to patient-centered medical homes. This is no small task. Practice facilitation, also called "coaching," is increasingly being used to support system change; however, there is limited guidance for these programs. OBJECTIVE: To develop an evidence-based curriculum to help practice coaches guide broad-scale transformation efforts in primary care. METHODS: We gathered evidence about effective practice transformation coaching from 25 published programs and 8 expert interviews. Given limited published information, we drew extensively on our experience as leaders and coaches in the Safety Net Medical Home Initiative. Using these data, and with input from a User Group, we identified 6 curricular topics and created learning objectives and curricular content related to these topics. RESULTS: The Coach Medical Home curriculum guides coaches in the following areas: getting started with a practice; recognition and payment; sequencing changes; measurement; learning communities; and sustainability and spread. CONCLUSIONS: Coach Medical Home is a publically available web-based curriculum that provides tools, resources, and guidance for practice transformation support programs, including practice facilitators and learning community organizers.

How 3 rural safety net clinics integrate care for patients: a qualitative case study.

BACKGROUND: Integrated care focuses on care coordination and patient centeredness. Integrated care supports continuity of care over time, with care that is coordinated within and between settings and is responsive to patients' needs. Currently, little is known about care integration for rural patients. OBJECTIVE: To examine challenges to care integration in rural safety net clinics and strategies to address these challenges. RESEARCH DESIGN: Qualitative case study. PARTICIPANTS: Thirty-six providers and staff from 3 rural clinics in the Safety Net Medical Home Initiative. METHODS: Interviews were analyzed using the framework method with themes organized within 3 constructs: Team Coordination and Empanelment, External Coordination and Partnerships, and Patient-centered and Community-centered Care. RESULTS: Participants described challenges common to safety net clinics, including limited access to specialists for Medicaid and uninsured patients, difficulty communicating with external providers, and payment models with limited support for care integration activities. Rurality compounded these challenges. Respondents reported benefits of empanelment and team-based care, and leveraged local resources to support care for patients. Rural clinics diversified roles within teams, shared responsibility for patient care, and colocated providers, as strategies to support care integration. CONCLUSIONS: Care integration was supported by 2 fundamental changes to organize and deliver care to patients-(1) empanelment with a designated group of patients being cared for by a provider; and (2) a multidisciplinary team able to address rural issues. New funding and organizational initiatives of the Affordable Care Act may help to further improve care integration, although additional solutions may be necessary to address particular needs of rural communities.

Impact of health claims in prebiotic-enriched breads on purchase intent, emotional response and product liking.

The impact of health claims on purchase intent, emotional response and liking has never been previously reported. In this study, prebiotic-enriched bread was used as a model functional food. Purchase intent, emotional response and liking were investigated in three phases: (1) focus groups were used to gauge consumer perception of health claims and functional foods, (2) the impact of health claims on purchase intent and emotional responses were measured using an online survey (n = 122) and (3) hedonic ratings on bread rolls presented with or without any associated claims were obtained (n = 100). A cluster analysis of the purchase intent data identified two clusters of consumers who were either receptive or non-receptive to health claims. Receptive and non-receptive consumers significantly differed in the emotions they reported with respect to the claims. The hedonic ratings did not significantly differ between the breads tasted with or without health claims.

Codesigning Online Continuing Medical Education on Social Health Integration and Social Risk-Informed Care for Primary Care Providers.

INTRODUCTION: Adapting clinical care decisions for patient-reported social risks is essential to social health integration and patient-centered care. Most research in this area focuses on awareness and assistance (social-needs-targeted care), such as screening and referral to food, financial, and other resources. Limited evidence for adjustment strategies (social risk-informed care) or adapting care for social risks made it difficult for Kaiser Permanente to implement new initiatives. This article describes a co-design process to build a novel, adjustment-focused continuing medical education course. METHODS: The authors co-developed the online continuing medical education course with patients and clinicians using user-centered design. Transcripts from co-design activities were coded and analyzed by thematic analysis to identify major themes, including perceptions of social risk-informed care and barriers to care adjustment. RESULTS: Practical hurdles for implementing social risk-informed care emerged, including clinicians' concerns about the ethics of adjustment as substandard care, particularly without robust assistance activities. However, patients expressed a desire for their care to be adapted to their social circumstances, to allow for more realistic care plans. DISCUSSION: Implementation barriers identified from the co-design were addressed through an interactive, case-study approach. Existing evidence on contextualized care and shared decision making informed a general framework for primary care providers to engage in awareness and adjustment activities, paired with 3 interactive case studies based on real-world, clinician-supplied scenarios. CONCLUSION: The authors recommend that multiple stakeholder perspectives be incorporated during the development of social health integration initiatives, particularly adjustment. Education complemented by active, nuanced, flexible implementation strategies may be necessary for the successful uptake of care-delivery-based social health integration activities.

Spreading a medical home redesign: effects on emergency department use and hospital admissions.

PURPOSE: The patient-centered medical home (PCMH) is being rapidly deployed in many settings to strengthen US primary care, improve quality, and control costs; however, evidence supporting this transformation is still lacking. We describe the Group Health experience in attempting to replicate the effects on health care use seen in a PCMH prototype clinic via a systemwide spread using Lean as the change strategy. METHODS: We used an interrupted time series analysis with a patient-month unit of analysis over a 4-year period that included baseline, implementation, and stabilization periods for 412,943 patients. To account for secular trends across these periods, we compared changes in use of face-to-face primary care visits, emergency department visits, and inpatient admissions with those of a nonequivalent comparison group of patients served by community network practices. RESULTS: After accounting for secular trends among network patients, patients empaneled to the PCMH clinics had 5.1% and 6.7% declines in primary care office visits in early and later stabilization years, respectively, after the implementation year. This trend was accompanied by a 123% increase in the use of secure electronic message threads and a 20% increase in telephone encounters. Declines were also seen in emergency department visits at 1 and 2 years (13.7% and 18.5%) compared with what would be expected based on secular trends in network practices. No statistically significant changes were found for hospital admissions. CONCLUSIONS: The Group Health experience shows it is possible to reduce emergency department use with PCMH transformation across a diverse set of clinics using a clear change strategy (Lean) and sufficient resources and supports.

Building Team-based Primary Care: Lessons From an Academic-Community Network Partnership.

BACKGROUND: Team-based care is fundamental to providing high-quality health care for patients. However, moving from a traditional, hierarchical way of providing care to team-based care is challenging and involves systematic and sustained process changes. OBJECTIVES: To describe the implementation and evaluation of a partnership between academics, clinic, and community to improve team-based care in primary care practices serving vulnerable populations utilizing a structured change package and implementation support. METHODS: The partners 1) created a six-strategy structured change package, 2) designed implementation support, and 3) evaluated implementation using an assessment scale at baseline and every 6 months. RESULTS: Practices improved in all care-team functions from May 2015 to August 2018, with the most improvement seen in population management, planned care and empanelment. CONCLUSIONS: Academic-community partnerships can use evidence-based practice supports to measurably improve team-based care in primary care practices serving vulnerable populations.

Assessing the Feasibility of an Empathic Inquiry Approach to Social Needs Screening in 10 Federally Qualified Health Centers.

OBJECTIVES: Despite an increasing emphasis from health care organizations on patients' social health, there is debate about how best to screen patients for social health needs in practice. Empathic Inquiry is a patient-centered approach to asking about patients' social needs that incorporates motivational interviewing and trauma-informed care techniques to increase patient experience of trustworthiness and safety with their care teams. The purpose of this brief report is to describe the feasibility and acceptability of implementing an Empathic Inquiry-informed approach to social needs screening in 10 federally qualified health centers. METHODS: Clinical staff at community health centers implemented Empathic Inquiry as part of an 8-month learning collaborative. Patients completed surveys about their experience with Empathic Inquiry after screening conversations took place. Qualitative data on organizational implementation experience were collected monthly during 2018. FINDINGS: Eight of 10 organizations completed the learning collaborative and implemented Empathic Inquiry in practice. Of 132 patient surveys received, patients agreed (64% strongly agree, 28% somewhat agree) that being screened for social needs strengthened their relationship with their care team and 83% strongly agreed the conversation was a good use of time. Most patients (54%) indicated social health screening was appropriate at every visit, and 27% answered once every 6 months. CONCLUSIONS: The Empathic Inquiry approach to understanding patients' social needs was feasible for implementation in community settings. Patients said the conversations were worthwhile, built trust with their care teams, and should be conducted every 6 months or more frequently.

Pragmatic Randomized Study of Targeted Text Message Reminders to Reduce Missed Clinic Visits.

INTRODUCTION: Missed clinic appointments ("no-shows") waste health system resources, decrease physician availability, and may worsen patient outcomes. Appointment reminders reduce no-shows, though evidence on the optimal number of reminders is limited and sending multiple reminders for every visit is costly. Risk prediction models can be used to target reminders for visits that are likely to be missed. METHODS: We conducted a randomized quality improvement project at Kaiser Permanente Washington among patients with primary care and mental health visits with a high no-show risk comparing the effect of one text message reminder (sent 2 business days prior to the appointment) with 2 text message reminders (sent 2 and 3 days prior) on no-shows and same-day cancellations. We estimated the relative risk (RR) of an additional reminder using G-computation with logistic regression adjusted for no-show risk. RESULTS: Between February 27, 2019 and September 23, 2019, a total of 125,076 primary care visits and 33,593 mental health visits were randomized to either 1 or 2 text message reminders. For primary care visits, an additional text message reduced the chance of no-show by 7% (RR = 0.93, 95% CI: 0.89-0.96) and same-day cancellations by 6% (RR = 0.94, 95% CI: 0.90-0.98). In mental health visits, an additional text message reduced the chance of no-show by 11% (RR = 0.89, 95% CI: 0.86-0.93) but did not impact same-day cancellations (RR = 1.02, 95% CI: 0.96-1.11). We did not find effect modification among subgroups defined by visit or patient characteristics. CONCLUSION: Study findings indicate that using a prediction model to target reminders may reduce no-shows and spend health care resources more efficiently.

A roadmap to operationalize and evaluate impact in a learning health system.

BACKGROUND: Many health systems invest in initiatives to accelerate translation of knowledge into practice. However, organizations lack guidance on how to develop and operationalize such Learning Health System (LHS) programs and evaluate their impact. Kaiser Permanente Washington (KPWA) launched our LHS program in June 2017 and developed a logic model as a foundation to evaluate the program's impact. OBJECTIVE: To develop a roadmap for organizations that want to establish an LHS program, understand how LHS core components relate to one another when operationalized in practice, and evaluate and improve their progress. METHODS: We conducted a narrative review on LHS models, key model components, and measurement approaches. RESULTS: The KPWA LHS Logic Model provides a broad set of constructs relevant to LHS programs, depicts their relationship to LHS operations, harmonizes terms across models, and offers measurable operationalizations of each construct to guide other health systems. The model identifies essential LHS inputs, provides transparency into LHS activities, and defines key outcomes to evaluate LHS processes and impact. We provide reflections on the most helpful components of the model and identify areas that need further improvement using illustrative examples from deployment of the LHS model during the COVID-19 pandemic. CONCLUSION: The KPWA LHS Logic Model is a starting point for future LHS implementation research and a practical guide for healthcare organizations that are building, operationalizing, and evaluating LHS initiatives.

An Expanded Role for the Medical Assistant in Primary Care: Evaluating a Training Pilot.

INTRODUCTION: The patient-centered medical home model stresses the importance of team-based care as a foundation to improving care, costs, and patient experience. Medical assistants (MAs) are being used as key care team members even as traditional educational programs may not equip them for this new way of working. METHODS: This paper describes an on-the-job, predominantly virtual training program aimed at building care teams by redefining the role of the MA and fostering team-based functioning. Participating MAs, clinic managers, and clinicians in 11 primary care clinics completed 18-item pre- and post-training surveys to assess confidence in MA skills and performance. In-depth 1-hour qualitative interviews were conducted with selected participating MAs, managers, and clinicians to assess MA self-efficacy and to understand their use of new skills. RESULTS: MAs, clinicians, and managers agreed that MAs improved skills in planned care and population management, self-management support and health coaching, and interdisciplinary communication and collaboration. MAs reported a positive training experience, that they shared their knowledge with other MAs in their clinic, and that their job satisfaction increased. DISCUSSION: A predominantly virtual 12-week program built the skills and confidence of MAs in proactive population management, health coaching, and collaboration and communication. This program shows the promise of a virtual approach to training that identifies, trains, and recognizes high-potential MAs.