Why did you go into primary care? Maybe you wanted to form lasting,
healing relationships with your patients. Maybe you wanted to provide
comprehensive "whole person" care and manage the health of a population.
Maybe you believe that primary care should be the backbone of our health
care system. Delivering patient-centered, comprehensive primary care is
hard work but you and your care team are ready to enhance the care you
deliver for all of their patients particularly those with complex
needs. Comprehensive Primary Care Plus or "CPC Plus" for short
brings together payers and clinicians to change the way primary care
practices have been doing business for decades. Primary care clinicians
want to provide the best care possible for their patients. They want to
ensure patients have access to care and build long-term relationships.
They want to more closely manage the health of their high risk patients.
They want to provide comprehensive services to their patients within
their practice, and be able to connect patients to high-value providers
outside their practice. They want to engage patients and their
caregivers to be active not only in their own health but also in the
improvement of the practice itself. And, they want to have data that
drives their quality improvement efforts and informs how best to care
for their patient population. These changes won't be easy and will take
time. They may even require a fundamental cultural shift. But, we're at
a turning point. CPC+ provides the tools, financial supports, and
guidance for practices to spend more time with patients, to deliver the
best care possible, and improve the health care system. In CPC+, we're
moving one step closer to placing patient relationships at the center of
what primary care clinicians do every day. So what will this look like
on the ground at your practice? It depends. CPC+ is organized into two
tracks based on practice capabilities and readiness to jump into the
work, and the way you implement CPC+ will reflect your specific patient
population and organizational structure. In the first year of CPC+,
Track 1 practices enhance important areas of their work: They'll develop
the foundation for team-based care by empanelling their entire
population of patients and ensuring?that patients have 24/7 access to
care informed by the Electronic Health Record; Track 1 practices will
also segment and stratify that patient population according to patient
risk; develop the capability to provide proactive, relationship-based
care management to those at highest risk; These practices will use payer
data to understand where their patients are receiving care and to focus
coordination efforts on hospital transitions and high volume
specialists; Practices will work to engage patients and families through
patient and family advisory councils in the design of care that best
meets their needs; Finally, Track 1 practices will review utilization
data provided by payers, to guide practice change. Track 2 practices
will strengthen all of the capabilities mentioned for Track 1 while they
also advance further: They will deepen their patients' access to primary
care by expanding the opportunities for care outside of the traditional
office visit. Track 2 practices will refine their risk-stratification
process and use care plans for these patients to assure the provision of
care consistent with the patient's goals and wishes. They will increase
their ability to coordinate the care of their population by enacting
collaborative agreements with specialists. To address their patients'
psychosocial needs, practices will begin to integrate behavioral health
care into their practice and inventory community and social supports
Track 2 practices will empower their patients to manage their chronic
conditions successfully by developing practice capability for support of
self-management. Practices will leverage the whole care team to develop
quality improvement strategies that use cost and utilization data. And
that's just the beginning. As practices become familiar with the initial
stages of delivering comprehensive primary care and gain expertise, they
will be ready to refine their work and will see opportunities to
continue to improve their patients' health outcomes. In CPC+, you will
work to transform your delivery of primary care, so that you can improve
the health of patients and their experience and quality of care, and
reduce unnecessary health care utilization. In the process, you may find
that you are fulfilling your passion for delivering primary care that
led you to go into the field in the first place.