Dipping a toe into the world that is CPC+

Editor's Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Lori E. Rousche, MD, a family physician in Souderton, Pennsylvania. She is also the hospice medical director for Grand View Health in Sellersville, Pennsylvania. The views expressed in these blogs are those of their respective contributors and do not represent the views of Medical Economics or UBM Medica.

Dr. RouscheComprehensive primary care plus (CPC+) is a program with goals to provide better patient care and decrease the cost of healthcare. There are five comprehensive primary care functions that CPC+ focuses on to meet this end. These five functions (taken from the Phase 1 CPC+ implementation guide) are:

1.     Access and continuity

2.     Care management

3.     Comprehensiveness and coordination

4.     Patient and caregiver engagement

5.     Planned care and population health

Over a five-year period, CPC+ will help practices measure their progress. Practices will report data through a portal and Centers for Medicaid and Medicare Services (CMS) will study this information and offer learning support and data feedback to aid practices in improving patient outcomes.

Further reading: Why physicians may want to apply for the CPC+ program

Let’s briefly break down the five functions to get a sense of what is required:

Access and continuity: Better access to providers and staff will allow for better care. Extended office hours decrease Emergency Department (ED) visits, and timely office visits to our sickest patients with continuity of care decreases hospital admissions.

A goal of CPC+ is to have practices enhance access and provide the right care at the right time. Practices can use extended office hours, phone visits and e-visits as alternate ways to reach patients.

Care management: Providers will identify high-risk patients through risk stratification and by event triggers (hospitalizations, ED visits, new serious diagnoses). The identified patients can be targeted for the extra help they need to prevent further events.

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For instance, a patient who was just in the ED with CHF should be contacted by phone and scheduled for a follow-up visit within one week of the ED discharge. Care management includes both long-term and short-term management. CMS will offer information to help with this including payer data. Our office has hired a nurse dedicated to the follow-up and care of these patients.

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Comprehensiveness and coordination: Comprehensiveness refers to the practice’s efforts to meet most patients’ medical, behavioral and social needs. If practices are able to do so, health outcomes should improve and utilization should decrease. CMS will provide analytics to aide in identifying the needs of a practice population. Once again, primary care providers will be the gateway.

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We will manage what we can within our office, and refer out what we cannot manage. Again, not a new concept to seasoned primarcy care physicians (PCP). CPC+ intends to build on this idea and have the primary care office be the hub to coordinate all care. Our seven-office primary care practice is considering hiring a social worker to help us with this aspect.

Patient and caregiver engagement: We all know that the patients who are vested in their health management generally have better outcomes. Each CPC+ practice will organize a Patient and Family Advisory Council (PFAC) to help patients and caregivers with the delivery of care and the management of their chronic conditions.

The PFAC will help providers stay focused on patient-centered care. Imagine if we could have all of our diabetics test their sugars and call them into the office as advised. This would go a long way to improving sugar control and hopefully decreasing complications.

Planned care and population health: Under CPC+, care will be team-based, focus on prevention and use evidence-based management of chronic diseases. Hopefully, CMS will provide the needed data to allow providers to understand population health and implement changes to stop the gaps in care. 

The Phase 1 CPC+ Implementation Guide is a 63-page document detailing some of the changes that practices are expected to make toward improving care. There is both a track 1 and a track 2, with track 2 assuming some risk. The payments CMS is giving to providers to achieve the goals of providing better care and decreasing cost while doing it are substantial.

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The money will need to be used by the practices toward the goal of care management. As mentioned, we have already hired a RN dedicated to the care and outreach of our most complicated patients, and are considering hiring a social worker and possibly a psychologist to better care for our patients.

 There will be many such improvements over the next five years, all aimed at improving how we deliver care. If we do it right, it’s a big win for the patients.