Editor's Note: 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 or UBM Medica.
Comprehensive 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.
In the news: CMS heads concerns, allows ACOs to join CPC+
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.