• families; and make high-quality, reliable tools available for shared decision making with patients at different levels of health literacy.
  • The Agency for Healthcare Research and Quality, partnering with the Centers for Medicare & Medicaid Services, other payers, and stakeholder organizations, should support the development and testing of an accurate and reliable core set of measures of patient-centeredness for consistent use across the health care system.
  • The Centers for Medicare & Medicaid Services and other public and private payers should promote and measure patient-centered care through payment models, contracting policies, and public reporting programs.
  • Digital technology developers and health product innovators should develop tools to assist individuals in managing their health and health care, in addition to providing patient supports in new forms of communities.

Beyond patient-centered care, this chapter has described how integrating services among and across health care organizations and community-based organizations can improve health and address complex care needs. Further, partnerships between health care organizations and public health systems can advance community health goals. Recommendation 5 describes the broad actions that different stakeholders need to take to improve coordination and partnerships between and among the health care system, community resources, and public health bodies. Further, the recommendation introduces two specific actions that can be taken to produce change immediately by rewarding care that improves population health and by increasing the accuracy of metrics that measure population health.

Recommendation 5: Community Links

Promote community-clinical partnerships and services aimed at managing and improving health at the community level. Care delivery and community-based organizations and agencies should partner with each other to develop cooperative strategies for the design, implementation, and accountability of services aimed at improving individual and population health.

Strategies for progress toward this goal:

  • Health care delivery organizations and clinicians should partner with community-based organizations and public health agencies to leverage and coordinate prevention, health promotion, and


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