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Care management bridges the gap between physician visits, providing the safety net patients desperately need. We quickly realized how valuable it was not only to have this position but also to have hired a social worker to fill it.

- Care Management in the Real World: A Small, Private Practice’s Journey, FPM 2021

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Why don't we have these conversations? Patients may not start them because they think it's too early to discuss the end of life. Physicians may not start them because we don't think it's the right time either, or we don't feel comfortable or confident enough.

- Advance Care Planning: How to Have the Conversation You Want With Your Patients, FPM 2019

For the industry to truly transform how it operates, innovation must take hold at all levels of an organization. Often, a seemingly simple idea can lead to huge change. The inaugural class of Top 25 Innovators found new ways to engage consumers, improve quality of care and lower costs.
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The goal, the entire reason for this transition, is so we can get to a system with better outcomes for patients, smarter use of resources, and family physicians who are finally rewarded for the high-quality care they deliver.

- Finding the Bright Spots in Value-Based Care, FPM 2017

In 10 years, we will have a sustainable health care system that plays a central role in improving the health of the US population. Individuals and the people who take care of them will understand their health, know when their health is deteriorating, and know how to get help (have a usual source of care). Technology will facilitate an ease of knowing, allowing individuals and their health care professionals to have a comprehensive view of their health, which includes individual, community, and environmental aspects of health, and to use this information in developing and executing personalized care plans.

- Vision for a Principled Redesign of Health Information Technology, Ann Fam Med 2017

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Sometimes you lose sight of why you are trying to solve a health problem – to actually create a long-term benefit in the individual patient’s health – when how to do it seems tedious and difficult.

- Controlling Hypertension: Focusing on “Why” Makes “How” a Lot Easier, FPM 2014


The Million Hearts® Hypertension Control Champions are clinicians, practices, and health systems that have successfully completed the Million Hearts® Hypertension Control Challenge. The Challenge is an opportunity for clinicians, practices, and health systems to demonstrate excellence in hypertension control.