- Clarify definitions and language
- Update recertification timeline to match legislative change
| Builds upon Foundational Level - Strengthen care coordination systems and partnerships across the medical neighborhood and community support system
- Enhance whole person integrated care models (behavioral/mental health, oral health, public health)
- Promote wellness, early intervention, and prevention
- Strengthen patient and caregiver engagement
- Screen, identify and address social determinants
- Expand registry work to include identification of health inequities and social needs, chronic conditions, and those with emerging risk for chronic conditions
- Augment cultural competency
- Enhance access
- Enhance referral network to include traditional and non-traditional resources
- Identify patient education opportunities
- Strengthen follow-up with referrals, admissions, discharges, transfers
| Builds upon Foundational and Level 2 - Integrate into a community health network
- Focus on population and community health
- High and continuously improving quality through a learning health system
- Focus on community health improvement
- Use data analytics to collaborate on community health data
- Expand care coordination team to community
- Secure exchange of information with clinical and community partners
- Develop shared care management processes
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