Primary Care Functions and Measures

Comprehensive Primary Care Plus

 Five Primary Care Functions:

  1. Access and Continuity - Practices will expand access to health care for their patients and create continuity in the care the patient is receiving from the practitioner and/or care team
  2. Care Management - Practices will risk stratify and care manage identified high-risk patients
  3. Comprehensiveness and Coordination - Practices will aim to meet the majority of the patient population's medical, behavioral, and health-related social needs
  4. Patient and Caregiver Engagement - Practices will organize a Patient and Family Advisory Council (PFAC) to help understand the perspective of patients and caregivers and the delivery of care
  5. Planned Care and Population Health - Practices will work to improve population health through the use of evidence-based protocols in team-based care and identification of care gaps at the population level

2018 CPC+ Care Delivery Requirements

Function 1: Access and Continuity
  Year 1 Year 2
Track 1 fjdfjkas Achieve and maintain at least 95% empanelment to practitioner and/or care teams Maintain at least 95% empanelment to practitioner and/or care teams
  Ensure patients have 24/7 access to a care team practitioner with real-time access to the electronic health record (EHR) Ensure patients have 24/7 access to a care team practitioner with real-time access to the EHR
  Organize care by practice-identified teams responsible for a specific, identifiable panel of patients to optimize continuity New: Measure continuity of care for empaneled patients by practitioners and/or care teams in the practice
Track 2 Achieve and maintain at least 95% empanelment to practitioner and/or care teams Achieve and maintain at least 95% empanelment to practitioner and/or care teams
  Ensure patients have 24/7 access to a care team practitioner with real-time access to the electronic health record (EHR) Ensure patients have 24/7 access to a care team practitioner with real-time access to the electronic health record (EHR)
  Organize care by practice-identified teams responsible for a specific, identifiable panel of patients to optimize continuity New: Measure continuity of care for empaneled patients by practitioners and/or care teams in the practice
  Regularly offer at least one alternative to traditional office visits to increase access to care team and clinicians in a way that best meets the needs of the population, such as e-visits, phone visits, group visit, home visits, alternate location visits (e.g., senior centers and assisted living facilities), and/or expanded hours in early mornings, evenings, and weekends Regularly deliver care in at least one way that is an alternative to traditional office visit-based care, meets the needs of your patient population, and increases access to the care team/practitioner, such as e-visits, phone visits, group visits, home visits, and/or alternative location visits (e.g., senior centers and assisted living facilities)
Function 2: Care Management
  Year 1 Year 2
Track 1 Risk stratify all empaneled patients

New: Use a two-step risk stratification process for all empaneled patients, addressing medical need, behavioral diagnoses, and health-related social needs:

Step 1: Use an algorithm based on defined diagnoses, claims, or other electronic data allowing population-level stratification; and

Step 2: Add the care team's perception fo risk to adjust the risk stratification of patients, as needed

  Provide targeted, proactive, relationship-based (longitudinal) care management to all patients identified as at increased risk, based on a defined risk stratification process and who are likely to benefit from intensive care management Based on your risk stratification process, provide targeted, proactive, relationship-based (longitudinal) care management to all patients identified as at increased risk, based on a defined risk stratification process and who are likely to benefit from intensive care management
  Provide short-term (episodic) care management along with medication reconciliation to a high and increasing percentage of empaneled patients who have an emergency department (ED) visit or hospital admission/discharge/transfer and who are likely to benefit from care management Provide short-term (episodic) care management, including medication reconciliation, to patients following hospital admission/discharge/transfer,* and, as appropriate, following and ED discharge
  Ensure patients with ED visits receive a follow-up interaction within one week of discharge Ensure patients with ED visits receive a follow-up interaction within one week of discharge
  Contact at least 75% of patients who are hospitalized in target hospital(s), within two business days

Contact at least 75% of patients who were hospitalized in target hospital(s),* within two business days

*including observation stays

Track 2

Use a two-step risk stratification process for all empaneled patients:

Step 1: Based on defined diagnoses, claims, or another algorithm (i.e., not care team intuition)

Step 2: Adds the care team's perception of risk to adjust the risk stratification of patients, as needed

Maintain and review a two-step risk stratification process for all empaneled patients, addressing medical needs, behavioral diagnoses, and health-related social needs

Step 1: Use an algorithm based on defined diagnoses,claims, or other electronic data allowing population-level stratification; and

Step 2: Add the care team's perception of risk to adjust the risk stratification of patients, as needed

  Provide targeted, proactive, relationship-based (longitudinal) care management to all patients identified as at increased risk, based on a defined risk stratification process and who are likely to benefit from intensive care management Based on your risk stratification process, provide targeted, proactive, relationship-based (longitudinal) care management to all patients identified as at increased risk, based on a defined risk stratification process and who are likely to benefit from intensive care management
  Provide short-term (episodic) care management along with medication reconciliation to a high and increasing percentage of empaneled patients who have an emergency department (ED) visit or hospital admission/discharge/transfer and who are likely to benefit from care management For patients receiving longitudinal care management, use a plan of care containing at least patient's goals, needs, and self-management activities that can be routinely accessed and updated by the care team
  Ensure patients with ED visits receive a follow-up interaction within one week of discharge

Provide short-term (episodic) care management, including medication reconciliation to patients following hospital admission/discharge/transfer, * and, as appropriate, following and ED discharge

*including observation stays

  Contact at least 75% of patients who are hospitalized in target hospital(s), within two business days Ensure patients with ED visits receive a follow-up interaction within one week of discharge
  Use a plan of care centered on patient's actions and support needs in management of chronic conditions for patients receiving longitudinal care management Contact at least 75% of patients who are hospitalized in target hospital(s), within two business days
Function 3: Comprehensiveness and Coordination
  Year 1 Year 2
Track 1 Systematically identify high volume and/or high-cost specialists serving the patient population using CMS/other payers' data New: Enact collaborative care agreements with at least two groups of specialists identified based on analysis of CMS/other payer reports
  Identify hospitals and EDs responsible for the majority of patients' hospitalizations and ED visits, and assess and improve timeliness of notification and information transfer using CMS/other payers' data Using CMS/other payers' data, track timeliness of notification and information transfer from hospitals and EDs responsible for the majority of patients' hospitalizations and ED visits
    New: Develop a plan for implementation of at least one option from a menu of options for integrating behavioral health into care, based on an assessment of practice capability and population need
Track 2 Systematically identify high volume and/or high-cost specialists serving the patient population using CMS/other payers' data Maintain collaborative care agreements with at least two groups of specialists identified based on analysis of CMS/other payer reports
  Identify hospitals and EDs responsible for the majority of patients' hospitalizations and ED visits, and assess and improve timeliness of notification and information transfer using CMS/other payers' data Using CMS/other payers' data, track and improve, as needed, the timeliness of notification and information transfer from hospitals and EDs responsible for the majority of patients' hospitalizations and ED visits
  Enact collaborative care agreements with at least two groups of specialists, identified based on analysis of CMS/other payer reports New: Develop a plan to provide comprehensive medication management to patients discharged from the hospital and those receiving longitudinal care management
  Choose and implement at least one option from a menu of options for integrating behavioral health into care Advance implementation of at least one option from a menu of options for integrating behavioral health into care
  Systematically assess patients' psychosocial needs using evidence-based tools

New: Address common psychosocial needs for at least your high-risk patients:

  • Routinely assess patients' psychosocial needs
  • Prioritized common needs in your practice population, and maintain an inventory of resources and supports available to address those needs
  • Establish relationships with at least two resources and supports that meet patients' most significant psychosocial needs
  Conduct an inventory of resources and supports to meet patients' psychosocial needs Define at least one subpopulation of patients with specific complex needs, develop capabilities necessary to better address those needs, and measure and improve the quality of care and utilization of this subpopulation
  Characterize important needs of subpopulations of high-risk patients and identify a practice capability to develop that will meet those needs, and can be tracked over time  
Function 4: Patient and Family Engagement
  Year 1 Year 2
Track 1 Convene a patient and family advisory council (PFAC) at least once in Program Year (PY) 2017, and integrate recommendations into care, as appropriate Convene a PFAC at least three times in PY 2 and integrate recommendations into care  and quality improvement activities, as appropriate
  Assess practice capability and plan for support of patients' self-management New: Implement self-management support for at least three high-risk conditions
Track 2 Convene a PFAC in at least two quarters in PY 2017 and integrate recommendations into care, as appropriate Convene a PFAC at least quarterly in PY 2, and integrate recommendations into care and quality improvement activities, as appropriate
  Implement self-management support for at least three high risk conditions Implement self-management support for at least three high-risk conditions
    New: Identify and engage a subpopulation of patients and caregivers in advance care planning
Function 5: Planned Care and Population Health
Track 1 Use feedback reports provided by CMS/other payers at least quarterly on at least two utilization measures at the practice-level and practice data on at least three electronic clinical quality measures (eCQMs) (derived from the EHR) at both practice- and panel-level to improve population health management Use feedback reports provided by CMS/other payers at least quarterly on at least two utilization measures at the practice-level and practice data on at least three electronic clinical quality measures (eCQMs) (derived from the EHR) at both practice- and panel-level to improve population health management
Track 2 Use feedback reports provided by CMS/other payers at least quarterly on at least two utilization measures at the practice-level and practice data on at least three electronic clinical quality measures (eCQMs) (derived from the EHR) at both practice- and panel-level to improve population health management Use feedback reports provided by CMS/other payers at least quarterly on at least two utilization measures at the practice-level and practice data on at least three electronic clinical quality measures (eCQMs) (derived from the EHR) at both practice- and panel-level to improve population health management
  Conduct care team meets at least weekly to review practice- and panel-level data from payers and internal monitoring and use this data to guide testing of tactics to improve care and achieve practice goals in CPC+ Conduct care team meets at least weekly to review practice- and panel-level data from payers and internal monitoring and use this data to guide testing of tactics to improve care and achieve practice goals in CPC+

 

Clinical Quality Measures (CQMs)  Review the measure specifications in the CMS eCQM Library.

Group 1: Outcome Measures
NQF CMS Description
0059 122v5  Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%)
0018 165v5  Controlling High Blood Pressure
Group 2: Other Measures
NQF CMS Description
0418 2v7  Screening for Clinical Depression and Follow-up Plan
  50v5  Closing the Referral Loop: Receipt of Specialist Report
0032 124v5  Cervical Cancer Screening
2372 125v5  Breast Cancer Screening
0043 127v6  Pneumococcal Vaccination Status for Older Adults
0034 130v5  Colorectal Cancer Screening
0055 131v5  Diabetes: Eye Exam
0062 134v6  Diabetes: Medical Attention for Nephropathy
0004 137v5  Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
0028 138v5  Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention
0101 139v5  Falls: Screening for Future Fall Risk
0041 147v7  Influenza Immunization
2872 149v6  Dementia: Cognitive Assessment
0022 156v5  Use of High-Risk Medications in the Elderly
0712 160v6  Depression Utilization of the PHQ-9 Tool
0068 164v6  IVD: Use of Aspirin or Another Antiplatelet
  347v1  Statin Therapy for the Prevention and Treatment of Cardiovascular Disease