Abhinav Shashank is the CEO and Co-Founder at Innovaccer, a big data and analytics company based out of Silicon Valley.

Comprehensive Primary Care Plus 101: The Dawn of Preventive Care

January 20, 2017 AT 3:41 PM

Today, healthcare services in the US are costlier than ever, but are they reciprocating the kind of health that was expected? Are we even close? Evidently, spending money won’t lead us anywhere unless we are moving in the right direction. It is important that we plot a roadmap to personalized care to get better generalized results.

What is Comprehensive Primary Care?

Centers for Medicare and Medicaid Services (CMS) has continually tried to bring innovations in the healthcare industry; however, their effectiveness is subject to implementation and support from various members of the healthcare community. One such innovation is Comprehensive Primary Care (CPC) which was started in October 2012 as a three-year model.

The primary focus of CPC model was to enhance the quality of care being delivered by implementing coordinated patient-centric care. For this, Comprehensive Primary Care had mentioned five functions that every practice in it had to fulfill.  Last summer, CMS announced an “upgrade” to CPC. The similar five functions are in CPC+ but enforced to greater depths.

What is Comprehensive Primary Care Plus?

Comprehensive Primary Care Plus will build on the foundation of CPC by integrating the important lessons learned from it. This five-year model will be even more comprehensive and elaborate to bring drastic changes in healthcare industry. It will have 2,500 practices as compared to 500 in CPC, 20,000 clinicians and 25 million patients involved. CPC+ is much more than the five functions of CPC; it has four basic drivers now that will change the care delivery process.

Driver 1: Comprehensive Care

CPC+ has been divided into Track 1 and Track 2. Just like CPC, it has five elements in it, but Track 2 will enforce them more effectively. The items of driver one are:

1. Access and Continuity: In this function, both Track 1 and Track 2 practices are required to:

·         Offer patients the 24/7 access to their practice.

·         Offer multi-point access to patients.

·         Patients should be able to access their real-time EHR.

·         Every patient must be assigned to a care team.

Besides these, Track 2 practices are required to offer more care options such as telephonic visits, e-visits, home visits and alternate location visit.

2. Care Management: Practices in CPC+ are required to do following things under Care Management:

·         Assign care teams to various patients

·         Stratify the population by risk

·         Identify the kind of care that’ll benefit patients, post which, provide that care

·         Provide self-management support, medication management, and behavioral health.

Track 2 practices should be capable enough to offer additional ability that can handle complex patients with multiple chronic conditions or other delicate conditions.

3. Comprehensiveness and Coordination: Practices are required to understand their patients better by knowing the medical neighborhoods of patients where they seek care. Practices in Track 2 are required to assess the patients’ psychological needs, patient support inventories and referrals.


4. Patient/Caregiver Engagement: Practices are expected to engage the patients and their families and involve them in shared decision making by using various technical aids such as motivational interviews or informative videos.

5. Planned Care and Population Health: Practices should be capable of providing timely care as needed. They should also manage the chronic conditions on the basis of past evidences.

Driver 2: Use of enhanced, accountable payment

Practices are required to develop analytic capabilities, project revenues, perform different budgeting exercises, utilize the care management fee to deliver comprehensive care and identify the areas where there is a scope for improvement.

Driver 3: Continuous Data Driven Improvement

Practices need to measure the quality of care being offered at practice, panel or care team level. Besides this, they should develop skills in change management and implement new workflow ideas on the basis of insights generated from the various data-driven approaches.

Driver 4: Optimal use of HIT

In both the tracks of Comprehensive Primary Care Plus, practices are required to have certified Health IT. The practices are supposed to have remote access to EHRs to ensure a 24/7 access.

Next: Technologys role in CPC+