The purpose of this study is to support enhancement, implementation, and evaluation of an improved model for delivering improved primary care to high-risk older adults through the use of health IT tools, focusing on issues related to the patient-centered primary care home (PCPCH) and other similar high-value elements that are proposed to improve patient outcomes. During this study, participating clinics will utilize the already-implemented Integrated Care Coordination Information System (ICCIS). Clinic staff will meet with a practice facilitator (monthly and as needed), and will track study activities and submit invoices via ICCIS reporting. These invoices will be used to simulate a shared savings model where clinics will be reimbursed based on their progress and effort towards their goals.

Clinics will set and work towards goals that they have chosen. Goals for the control arm are self-selected by the clinics themselves; goals for the invention arm are related to high-value elements (HVE) that have been identified as areas that can improve patient outcomes. These HVE are:

1. Evidence-based Care Management Based on Need
2. Identification of At-Risk Populations
3. Patient Engagement and Alerts Based on Goals
4. Integrated Information for Care Management, especially around Utilization
5. Population Management Tools

Inclusion Criteria:

• clinics must be from the Oregon Rural Practice-based Research Network (ORPRN)
• Primary care clinic meeting one of the following health care setting descriptions: 1) small clinics in rural area, 2) medium-sized clinics in rural area, 3) clinics in moderate-sized health system, or 4) clinic within an academic medical center;
• Clinic will or has attested for PCPCH, achieving Tier 2 or 3 (of 3 tiers);
• Clinic is willing to contract to be a PCPCH with payers;
• Clinic has stable electronic health record (EHR) system with no plans to change systems during study duration;
• Clinic has willingness to receive practice facilitation and participate in study activities, including completion of assessments;
• Clinic has willingness to engage with research team members as defined in the study.

Exclusion Criteria:

• patients less then 18