Changes physicians will need to make under CPC+ explained

PCPs seeking to enroll in CMS’ new Comprehensive Primary Care Plus, also known as CPC+, program will be required to make multiple changes during its initial year, affecting various aspects of their practices including care management, Medicare management fees and access to patients.

Physicians and practices in selected regions will be able to begin applying to join the new 5-year, primary care medical home model on July 15. Designed as an extension of the Comprehensive Primary Care (CPC) initiative, which began in October 2012 and will end on Dec. 31, 2016, CPC+ aims to improve primary care through payment reform and changes to care delivery.

“Primary care is central to a high-functioning health care system,” Laura L. Sessums, JD, MD, of the CMS’ Center for Medicare and Medicaid Innovation, and colleagues wrote in a viewpoint article explaining CPC+, published in JAMA’s June issue. “Advanced primary care medical homes are practices supported by payment, health information technology, and data that transform their delivery of care while accountable for the cost and quality of care their patients receive. Regardless of size or ownership structure, these practices can likely improve the quality and experience of care for their entire population of patients. These changes also could lead to reductions in unnecessary health care utilization and cost of care.”

CPC+ will create a two-track system of payments and care delivery. Practices in both tracks will be required to make changes over the course of 5 years to various aspects of their operation, including care access and continuity, care management, comprehensiveness and coordination, patient and caregiver engagement, and planned care and population health.

Below is a breakdown of all of the required first-year changes under both CPC+ tracks, for each primary care function. Practices in track 2 would also be required to meet the standards detailed in track 1. Those in track 1 that participated in the initial CPC program are expected to continue their ongoing, mandated changes in PY2017.

Access and Continuity

Track 1:

Achieve and maintain at least 95% empanelment to practitioner and/or care teams;
ensure patients have 24/7 access to a care team practitioner with real-time access to electronic health records; and
organize care by practice-identified teams responsible for a specific, identifiable panel of patients.

Track 2:

Regularly offer at least one nontraditional type of office visit, such as e-visits, phone visits, group visits, home visits, visits to alternative locations (e.g.: senior centers and assisted living centers), and/or expanded hours in the early mornings, evenings and weekends.

Care Management

Track 1:

Risk-stratify all empaneled patients;
provide targeted, proactive, relationship-based care management to all patients who are identified as at increased risk, based on risk-stratification and on patients who are likely to benefit from intensive care management;
provide short-term, episodic care management and medication reconciliation to a high and increasing percentage of empaneled patients who have an ED visit or hospital admission, discharge or transfer, and who are likely to benefit from care management;
ensure patients with ED visits receive a follow-up within 1 week of discharge; and
contact at least 75% of patients who were hospitalized in target hospitals within 2 business days.

Track 2:

Use a two-step risk stratification process for all empaneled patients, adding the care team’s perception of risk, adjusting patient status as needed; and
use a plan centered on patient’s actions and support needs in the management of chronic conditions for patients receiving longitudinal care management.

Comprehensiveness and Coordination

Track 1:

Systematically identify high-volume and/or high-cost specialists serving local patients using CMS’ and other payer’s data; and
identify hospitals and EDs with the highest number of patient visits, and improve timeliness of notification and information transfer using CMS’ and other payers’ data.

Track 1 for those already enrolled in the initial CPC program:

Maintain or enact collaborative care agreements with at least two groups of specialists identified from CMS and other payer reports; and
Choose and implement at least one option for integrating behavioral health into care.

Track 2:

Establish collaborative care agreements with at least two groups of specialists identified through CMS and other payers’ reports;
choose and implement at least one option for integrating behavioral health into care.
assess patients’ psychosocial needs using evidence-based tools;
perform inventory of resources and supports to meet patients’ psychosocial needs; and
identify high-priority needs of subpopulations of high-risk patients and create a strategy to meet those needs, tracking progress over time.

Patient and Caregiver Engagement

Track 1:

Convene a Patient and Family Advisory Council (PFAC) at least once in PY2017, and integrate recommendations into care as appropriate; and
assess practice capability and plan for support of patients’ self-management.

Track 1 for those already enrolled in the initial CPC program:

Convene a Patient and Family Advisory Council (PFAC) in at least two quarters during PY2017, and integrate recommendations into care as appropriate; and
implement self-management support for at least three high-risk conditions.

Track 2:

Convene a Patient and Family Advisory Council (PFAC) in at least two quarters during PY2017, and integrate recommendations into care as appropriate; and
implement self-management support for at least three high-risk conditions.

Planned Care and Population Health

Track 1:

Use feedback reports from CMS and other payers at least quarterly on at least two utilization measures at the practice level, and practice data on at least three electronic clinical quality measures at both practice and panel level, to devise strategies to improve population health management.

Track 2:

Conduct care team meetings at least weekly to review practice- and panel-level data from payers and internal monitoring, and use this data to test strategies to improve care and achieve CPC+ practice goals.

“CPC+ builds on lessons learned to date from CPC — and other medical home models — and seeks to provide practices with the resources, information and incentives that best support the delivery of the five functions of advanced primary care,” Sessums and colleagues wrote in JAMA. “A continuously improving health care system requires ongoing innovation and improvement. Nowhere is that more important than in primary care, the foundation of the delivery system.” – by Jason Laday

Additional reading:

https://innovation.cms.gov/initiatives/comprehensive-primary-care-plus

https://innovation.cms.gov/Files/x/cpcplus-practicecaredlvreqs.pdf