Advanced Primary Care Innovation Center

Programs Offered

The Advanced Primary Care Innovation Center at WVU Family Medicine includes several programs to meet the needs of patients, the institution, and the state. These programs are continually filtered through the Quality and Performance Improvement Director to provide the best possible care to all constituents.

Existing Programs

  • Population Health Management in Primary Care Fellowship Facilitate transformation of primary care delivery into a patient-centered medical home model to promote compassionate, appropriate and effective patient care. Further develop clinical skills as a primary care physician including team-based and inter-professional models of care delivery.
  • Team Care  Team Care is a program applying the advanced primary care model using the STEPS Forward program of the American Medical Association.[1] In collaboration with Cleveland Clinic, WVU Family Medicine is expanding on a new model of care that combines efficiency, quality, and more face-to-face time with patients.
  • Intensive Primary Care Diabetes Clinic  The Intensive Primary Care Diabetes Clinic is a multidisciplinary weekly clinic for new patients or for those with poor diabetes control. It is staffed by a coordinated team of physicians, residents, nurses, pharmacists, psychologists, Certified Diabetes Educators, Registered Dietitians, and nurse care coordinators.
  • COPD/Asthma Clinic  The COPD/Asthma clinic is an advanced primary care multidisciplinary weekly clinic for patients with lung disease who need more comprehensive evaluation and treatment. Pulmonary functions tests (office spirometry) is conducted on all patients and the clinic includes immunization care, referrals for lung cancer screening, and follow up visits as needed. It is attended by a faculty physician, pharmacist, dietician/smoking cessation counselor, respiratory therapist (when available), medical students, and pharmacy students at all levels.
  • Annual Wellness Visits and Training Program Annual wellness visits are available to Medicare patients at any time throughout the year. The Annual Well Visit Training Program is available for physicians, nurses, and APP’s.
  • Acupuncture Medical Acupuncture is a treatment that is provided by physicians trained in acupuncture. The treatment consists of placing very tiny needles in the body in a certain pattern to help with medical problems. It is not designed to replace the treatment that you receive from your physician but rather to enhance medical treatment.
  • Good Measures, LLC   An innovator in the nutrition space, Good Measures, LLC provides breakthrough technology and clinical coaching to cost-effectively help people improve eating and exercise habits for better nutrition balance.
  • Care Coordination – Transitional Care Management  Care coordination of primary care patients is available and ongoing, including both Transitions of Care Management (TCM) and Chronic Care Management (CCM) program patients. Care coordination training is available for nurses and APP’s
  • Live Well Programs  Live Well programs promote a prevention and wellness culture in the community. Health professional coaches provide personalized service to any interested patient to facilitate the easy navigation of the many services provided and to ensure they fit the individual’s needs. These programs provide innovative and patient-oriented care in an accessible location.

Developing Programs

  • Population Health Management in Primary Care Fellowship  The Population Health Faculty Development Fellowship is a two-year fellowship that combines the curriculum of Masters in Public Health in Health Policy with the Family Medicine Faculty Development PCMH Fellowship, in collaboration with the School of Public Health. It includes a MPH or MSCR degree from WVU School of Public Health, clinical care and sing health information technology, data analytics, and population health tools to support advanced primary care.
  • Patient Navigation Training Program  The Patient Navigation Training Program is conducted in coordination with the WVU School of Public Health and assists in the clinical training of bachelor’s degree students in the undergraduate patient navigation program. Patient navigator students will be hosted and exposed to the primary care environment and taught care coordination with specialties, the hospital, and the community.