Comprehensive Primary Care Plus (CPC+): breaking down the five functions

By and Cathi Burkham, RN, MSN | 6 minute read | September 30, 2016

Donna Daniel, PhD, is a Senior Program Director of Clinical Quality Research at IBM Watson Health
Cathi Burkham, RN, BSN, is a health informaticist at IBM Watson Health

Last April, there was much excitement in the primary care world when the Centers for Medicare & Medicaid Services (CMS) announced Comprehensive Primary Care Plus (CPC+), the largest advanced primary care medical home care delivery and payment model. Advanced primary care medical homes are practices supported by payment, health information technology, and data that transform their delivery of care while taking accountability for the cost and quality of care their patients receive. Ultimately, the CPC+ model supports the goals of better care, smarter spending, and healthier people.

CMS used feedback and analysis of the original CPC initiative to create the CPC+ Theory of Action and Driver Diagram
(CPC initiative).1

In addition to serving as the logic model for value-based transformation, this diagram outlines the five core functions that will be the roadmap toward a whole-person, patient-centered, comprehensive primary care delivery model.

CPC+ Theory of Action and Driver Diagram

Many providers who did not participate in the original CPC initiative are asking themselves what they need to do to achieve excellence the five core functions. The good news is that the CPC+ functions are not a list of concepts unique to the imagination of CMS. Rather, they are the foundation of the Patient Centered Medical Home (PCMH) model with the addition of payers’ alignment with CMS for payment and reporting requirements. CMS is aware that practices are at varying levels of experience with care delivery transformation and readiness to jump into the CPC+ redesign that CMS envisions, so there are two CPC+ tracks with differing eligibility, care delivery, and health IT requirements. Track 1 is the framework for delivering better care, improving health outcomes, and reducing the cost of care. Track 2 builds upon
Track 1 requirements by expecting practices to focus on their patients with complex needs. Practices will have five years during this program to transform their care delivery.

5 Comprehensive Primary Care Plus Functions

The CPC+ function examples are not a checklist or a comprehensive set of guidelines for CPC+. The objective of the five functions is to offer a pathway for practices to become successful over time. CMS has offered this pathway to help practices improve quality measures, utilization, and patient experience, including the potential for patient-reported outcomes measures (PROM).

Function 1: Access and Continuity

When patients have access to their primary care team, costly urgent care or emergency room visits can be avoided.

Ensuring continuity of care with consistent providers and care team members also aims to build a trusting relationship between the patient and caregiver resulting in greater patient engagement.

Function 1: Examples

Track 1 Track 2
Provide 24/7 Patient Access to a care team (or covering care team) with
real-time access to the electronic medical record
Offer Alternative Visits to reduce barriers to timely care, such as
e-visits, phone visits, group visits, etc.
Empanel Patients or assign patients to a specific provider / care team
to ensure continuity of care
Offer Expanded Office Hours to better accommodate patient schedules and
avoid the alternative of urgent care or emergency room visits

Function 2: Care Management

Care management of patients with highest need (e.g., multiple chronic conditions) and those at highest risk (e.g.,
for hospitalization), is a main component of providing exceptional primary care. Identifying patients in need of
care management services and providing longitudinal, relationship-based and episodic (following hospitalization or
an emergency department [ED] visit) care management to at-risk populations can significantly improve health

Function 2 Examples:

Track 1 Track 2
Stratify Patients by risk score to identify those with the greatest
need for care management services
Provide Care Plans for high-risk patients and ensure the care plans are
followed through or adjusted to meet the patient’s and care team’s needs
Contact Patients discharged from the hospital and follow-up with
patients having ED visits in a timely fashion to enable a safe, patient-centered transition back to
primary care
Use a Two-Step Risk Stratification process to allow for input from the
care teamStep 1: Stratify based on diagnoses or claims

Step 2: Stratify based on care team’s perception of risk

Build Practice Capabilities in behavioral health, self-management
support, and medication management to best support whole-person care and patient engagement
Build Additional Practice Capabilities in assessment and management of
patients with complex needs, such as those with cognitive impairment, frailty, or multiple chronic
conditions to best meet patients’ needs


Function 3: Comprehensiveness and Coordination

The comprehensiveness and coordination function aims to keep the patient in-house, providing services within the office, rather than in other care locations. If the patient must go outside the practice for a service, the care team will take an active role in coordinating that care and be the patient’s main hub or medical home, always aware of care the patient is receiving outside the office. CMS believes higher levels of comprehensive care are associated with better health outcomes and lower overall utilization and costs.

Function 3 Examples:

Track 1 Track 2
Facilitate Coordination of Care by understanding  where in the “medical
neighborhood” patients receive care
Offer Comprehensive Care as described in CMS’ Chronic Care Management
Improve the Transitions of Care by working more closely with hospitals
and emergency departments, as well as with at least one high volume specialty service provider
Conduct Systematic Assessments of patients’ psychosocial needs and
build an inventory of resources and supports to meet those needs
Enact Agreements with specialists to ensure coordinated care Provide Referrals to identified community/social services as needed


Function 4: Patient and Caregiver Engagement

Getting patients involved in the management of their own care is important. CPC+ practices will create a Patient and Family Advisory Council (PFAC) to understand the perspective of the patient. The PFAC will help the practice improve care.

Function 4 Examples:

Track 1 Track 2
Convene a PFAC at least once in PY2017, and integrate recommendations
into care, as appropriate
Convene a PFAC in at least two quarters in PY2017 and integrate
recommendations into care, as appropriate
Engage Patients in goal setting and shared decision-making, using
decision aids and specific techniques (e.g., motivational interviewing) to support patients in
Provide Self-Management Support as well as support for caregivers of
persons with functional disabilities (e.g., dementia)


Function 5: Planned Care and Population Health

Practices will scale population health efforts by using evidence-based protocols and team-based care to identify and close patient care gaps, ultimately improving the health of their patients.

Function 5 Examples:

Track 1 Track 2
Use Payer Reports to identify and improve on measures Hold Weekly Care Team Meetings to review data and strategize to improve
care delivery and goals
Develop an understanding of the practice’s patient population and develop the capability
to Measure and Act on the quality of care at both the practice and panel levels
Integrate support for self-management of care systematically and understand and
Address Health Disparities in the population

At IBM Watson Health, we are dedicated to helping your organization meet the CPC+ requirements. Our solutions
support both the care delivery functions and health IT requirements. IBM Watson Health is available to provide your
organization with a letter of support for your CPC+ application (due September 15).

The table on page 6 of this Executive Summary
outlines how our solutions align with the five CPC+ care delivery functions. Please stay tuned for our upcoming blog post on how our solutions support the CPC+ health IT requirements.

Learn more about what each function means at the practice level: CPC+
Practice Care Delivery Requirements


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