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Greater Columbia Cares Model

Transforming Healthcare Delivery


Health organizations spend all their time providing care. Changing the way they deliver that care is often the last thing on their minds. However, implementing evidence-based changes to adjust care delivery can improve patient access, while at the same time easing the burden and burnout often felt by providers.


  • Increase touchpoints with patients
  • Provide better, patient-centered care
  • Improve health outcomes
  • Increase access to care
  • Reduce emergency visits
  • Achieve payment incentives for meeting performance goals


By the second year of the program, GHN partnered with 83 organizations across the region. These organizations have continued on to their third and fourth years, and have shown great improvement in areas including collaboration/compact agreements with other organizations, population health, transitional care—especially 7-day follow up for Emergency Department and Inpatient, reduction in 30-day readmission, quality improvement, and infrastructure.


The Greater Columbia Cares Model (GCCM) toolkit applies not only to primary care clinics, but also to hospitals, behavioral health organizations, substance use disorder facilities, and more. This program allows healthcare organizations to build the processes needed to understand patient populations, find needed resources, integrate the patient voice, and provide self-management support—all while achieving payment incentives for reaching performance milestones.

The GCCM is a comprehensive model utilizing evidence-based initiatives including the Chronic Care Model, Six Building Blocks, Comprehensive Primary Care Initiative, and population health concepts such as social determinants of health, health equity, and risk stratification. Through the implementation of GCCM, partnering providers are working towards value-based payment and achieving population health across our region.

The model is structured, rather than prescriptive, and designed to fit the needs of the organization. The GCCM Implementation & Reporting Toolkit outlines each milestone by intent, work, and reporting requirements needed to complete and achieve these milestones.