This is how CPC+ is changing physician offices for the better

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.

Comprehensive Primary Care Plus (CPC+), the new model for primary care in America, is changing the way physicians run their offices in a revolutionary way. I am seeing many improvements in outreach to our most complicated patients and hopefully will see improved outcomes and enhanced care going forward. Let’s take a look at the evolving role of the clinical staff in regards to the quality measures that the government is tracking:

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There are 14 electronic Clinical Quality Measures (eCQMs) that will be scored for our involvement in CPC+. (More information on the Quality Payment Program and MIPS can be found at https://qpp.cms.gov/.)  Nine of these measures must be reported on for our first year of involvement. For the 2017 reporting period, a practice must choose to report results on two of the three outcome measures. The three measures are: depression remission at twelve months, controlling high blood pressure, and diabetes: hemoglobin A1c poor control with result greater than 9%.

Practices must also report on two of the four complex care measures: use of high-risk medications in the elderly; dementia cognitive assessment; falls, screening for future fall risk; and initiation and engagement of alcohol and other drug dependence treatment.

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

In addition, an office must pick to report on five of the ten remaining measures from the outcome measures or the complex care measures, or from the seven choices as follows: closing the referral loop (receiving a specialist report); communication and care coordination; cervical cancer screening; diabetes eye exams; preventive care and screening of tobacco use; population health; use of imaging in low back pain, efficiency and cost reduction; and breast cancer screening.

To accurately track these measures and to reach out to patients to fulfill these actions requires a joint effort from all of the office personnel. We have doled out some of these responsibilities to our administrative staff and some of them to the clinical staff.

Next: This is how we do it

Here are the enhanced responsibilities of our clinical employees.

Our nursing staff does not just “room” a patient in the traditional sense. Besides taking the blood pressure and noting the chief complaint, there are many boxes that need to be checked in the electronic health record (EHR) upon arrival in the examination room in order to fulfill our metrics.

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For instance, as part of the readying process, a clinical staff member (MA, LPN, RN) will ask the patient about tobacco use. If the patient say yes, the staff needs to be sure the boxes are checked in the EHR giving us credit for counseling the patient to stop smoking. A handout will be given, and the physician will discuss this with the patient during the office visit. However, just documenting this in your note does not allow tracking that it was done. What the nurse enters in the social history includes the date of the visit and allows us to capture the counseling in the EHR.

The clinical staff also asks the patient the questions from the PHQ-9 (Patient Health Questionnaire with 9 depression related questions) if the patient carries a diagnosis of major depression. This will also be captured and tracked. The provider, of course, reviews this with the patient during the office visit. If the PHQ-9 score is not below 5, the physician should be making an attempt to improve management.

The clinical staff is also responsible for asking about falls and recording this appropriately in the EHR so that we get credit for this measure. If the patient is a fall risk, the nursing staff provides the patient with a handout to help reduce the risk, and again, the provider will discuss this at the visit and review the patient’s medications for potential side effects that will increase fall risk.

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One of the more recent tasks we added for our clinical staff is dementia screening on any patient who carries that diagnosis. This also needs to be entered in the EHR so as to be captured when we report our metrics. The nurse does the mini mental status or the AD-8 (Eight-item Informant Interview to Differentiate Aging and Dementia) and enters the score. (We also have our nurse do the clock draw test, although this is not added as captured data.) The provider again reviews this with the patient and offers appropriate management.

Next: "A colossal collaboration"

Our clinical staff also does pre-visit planning on all of our patients. Before the patient comes in for the visit, a staff member looks through the problem list and correspondence and enters in the chief complaint (CC) health maintenance items that are due. For instance, if a diabetic patient has not had their eye exam, foot exam, A1C or urine for microalbumin, this will be listed in the CC and remind the provider from the beginning of the visit to get these ordered. It is the same with colon cancer, breast cancer and osteoporosis screening.

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It is a colossal collaboration between all of the office personnel to try to record the required metrics, and to reach the quality goals set by CPC+ is an even more difficult process. The responsibilities of our clinical staff when rooming a patient have increased phenomenally.

Just as the government and insurance companies continue to request more and more from providers, we are asking more and more of our employees. Hats off to the nursing staff for their efforts to improve quality and tracking in the hopes of improving quality of care.