What topics should I focus on as a healthcare provider?

Core Focus Areas for Healthcare Providers

As a healthcare provider, you must prioritize building systems-level competencies in chronic disease management, patient safety practices, and evidence-based care delivery while simultaneously developing skills to address social determinants of health and foster team-based, patient-centered care. 1, 2

1. Systems-Based Chronic Disease Management

Adopt and implement the Chronic Care Model framework as your foundational approach to patient care, which emphasizes person-centered team care, integrated long-term treatment approaches, and ongoing collaborative communication between all team members. 1

The six core elements you must master include: 1

• Delivery system design: Transform from reactive to proactive care delivery with planned, coordinated team-based visits
• Self-management support: Equip patients with tools and education for autonomous disease management
• Decision support: Base all care decisions on evidence-based, effective care guidelines
• Clinical information systems: Utilize registries providing patient-specific and population-based support
• Community resources and policies: Identify and develop resources supporting healthy lifestyles
• Health systems integration: Create and maintain a quality-oriented organizational culture

Evidence demonstrates that implementing the CCM reduces cardiovascular disease risk by 56.6%, microvascular complications by 11.9%, and mortality by 66.1%, while generating healthcare savings of $7,294 per patient over 5 years. 1

2. Evidence-Based Practice Implementation

Master the integration of evidence-based guidelines into daily clinical decision-making, as EBP consistently links to improved quality of care, patient safety, and positive clinical outcomes. 3

Key competencies include: 4

• Knowledge acquisition: Develop skills to critically appraise and synthesize current research literature
• Clinical application: Translate evidence into actionable treatment protocols and standardized care pathways
• Performance measurement: Use validated outcome measures rather than self-reported assessments
• Continuous evaluation: Monitor implementation fidelity and patient outcomes systematically

A critical caveat: While healthcare professionals report moderate to high EBP knowledge and positive attitudes, this does not consistently translate into actual implementation—you must bridge this gap through deliberate practice and system support. 4

3. Patient Safety and Quality Improvement

Implement proven patient safety practices that directly reduce morbidity and mortality, focusing on high-impact interventions with strong evidence. 5

The highest-priority safety practices you should master include: 5

• Venous thromboembolism prophylaxis: Appropriate use in at-risk patients
• Perioperative beta-blockers: For appropriate surgical candidates
• Central line infection prevention: Maximum sterile barriers during insertion and antibiotic-impregnated catheters
• Surgical antibiotic prophylaxis: Timely and appropriate administration
• Informed consent verification: Have patients recall and restate information
• Pressure ulcer prevention: Use of pressure-relieving materials
• Real-time ultrasound guidance: For central line placement

Create a safety culture by: 1

• Starting every team meeting with a 2-3 minute "safety story" highlighting good catches or learning opportunities
• Implementing standardized protocols and checklists with adherence monitoring
• Establishing nonpunitive error-reporting systems
• Conducting interprofessional team reviews of reported events

4. Social Determinants of Health Assessment

Systematically assess and address social determinants of health in every patient encounter, as these factors heavily influence medical and psychosocial outcomes and often remain undiscussed. 1

You must routinely evaluate: 1

• Food security status: Access to adequate, nutritious food
• Housing stability: Safe, consistent living arrangements
• Financial barriers: Medication costs, transportation to appointments, copayments
• Health literacy: Ability to understand and act on medical information
• Community support: Availability of family, social, or professional support systems

A critical pitfall: Up to two-thirds of patients with cost-related medication nonadherence never disclose this to their physician—you must proactively ask about these barriers. 1

Connect patients to: 1

• Local community resources and support programs
• Lay health coaches, navigators, or community health workers
• Financial assistance programs for medications and diabetes technology

5. Team-Based Care Leadership

Develop competencies in leading and participating in interprofessional care teams that include nurses, dietitians, pharmacists, and other providers. 1

Essential team-based skills include: 1

• Collaborative goal-setting: Explicit, shared objectives with patients and team members
• Barrier identification: Addressing language, numeracy, or cultural obstacles to care
• Performance feedback: Regular review of team and individual metrics
• Structured care protocols: Implementing and monitoring adherence to evidence-based pathways
• Therapeutic inertia avoidance: Timely intensification of lifestyle and pharmacologic interventions

Leverage technology to enhance team function: 1

• Utilize interconnected electronic health records
• Implement decision support tools
• Maintain patient registries for population health management
• Facilitate both in-person and virtual team-based care delivery

6. Multimorbidity and Complexity Management

Master a 4-domain framework for managing patients with multiple chronic conditions, as these patients account for 50% of healthcare costs while comprising only 26% of the population. 1, 2

The four domains to assess and address are: 1

• Medical care and treatments: Disease-specific interventions and medication management
• Physical health and functioning: Ability to perform daily tasks and maintain independence
• Emotional and mental health: Psychological well-being, stress, sleep, and coping
• Environmental factors: Living/working conditions, health literacy, access barriers, financial concerns

Prioritize therapy based on patient goals, preferences, and life phase rather than treating each condition in isolation. 1

7. Quality Measurement and Improvement

Engage in continuous quality assessment using reliable data metrics to improve care processes and health outcomes. 1

Focus on: 1

• Monitoring diabetes health care maintenance metrics (glycemic control, blood pressure, lipid management, preventive screenings)
• Tracking medication adherence at the systems level
• Evaluating care costs alongside clinical outcomes
• Participating in benchmarking programs
• Leading or contributing to practice-based quality committees

Adopt a culture of quality improvement by implementing structured programs that support sustainable, scalable process changes. 1

8. Health Equity and Vulnerable Populations

Develop specialized approaches for underserved and vulnerable populations to address documented health inequities in chronic disease outcomes. 1, 2

Key actions include: 1

• Incorporating standardized sociodemographic variables in documentation
• Measuring health inequities and intervention impacts systematically
• Advocating for policies that reduce barriers to care
• Expanding access through telemedicine for rural or underserved populations
• Addressing cost barriers to medications, particularly insulin

9. Patient-Centered Communication

Master communication techniques that ensure treatment decisions align with individual patient preferences, prognoses, comorbidities, and values. 1

Essential communication skills: 1

• Eliciting and documenting patient goals for care
• Discussing topics patients may hesitate to raise (financial concerns, medication costs, transportation barriers, emotional health)
• Ensuring patients understand and can restate key information
• Addressing treatment burden and patient capacity for self-management
• Facilitating shared decision-making that respects patient autonomy

10. Continuous Professional Development

Maintain current knowledge through interprofessional education and participation in patient safety programming at national and regional meetings. 1

Commit to: 1

• Expanding working knowledge of patient safety issues and best practices
• Participating in available safety programming
• Sharing patient safety issues and best practices with colleagues
• Including patient safety curricula in any teaching or mentoring roles
• Taking individual responsibility for awareness of emerging safety concerns

The evidence overwhelmingly demonstrates that these competencies—when implemented systematically—improve patient outcomes, reduce healthcare costs, and generate positive return on investment for healthcare systems. 3 Ninety-four percent of evidence-based practice implementations show positive ROI, with none showing negative ROI. 3