Russell Kohl, MD, FAAFP Medical Director TMF Health Quality Institute What Works in PCMH Preliminary Lessons from the Comprehensive Primary Care Initiative Russell Kohl, MD, FAAFP Medical Director TMF Health Quality Institute

Preliminary Learnings Outcomes of Year 2 Initial Analysis These results suggest that a data- driven, customized intervention can improve quality of care and patient experience without an increase in total cost of care, while simultaneously transitioning practices to a population based payment model No Statistically Significant Change Transition from Fee for Service to Population Based Cost of Care Reduction of Hospital Admissions Reduced ED Utilization Quality of Care Improved CAHPS Scores Increased Deployment of Patient/Family Advisory Committees Experience of Care

CPC Functions Risk Stratified Care Management Iterative Subjective Adaptations Optimize Intervention Populations Patient/Family Advisory Councils Engaged/Empowered Working Beyond “Satisfaction” “Practice Ambassadors” To Your Community

CPC Functions Transitions of Care Teams (AR) Engage Community Partners Collaboration Culture (CO) Best Practices Sharing Team Based Care Top of Licensure Protocols

Continuous Improvement Driven By Data Comparative Data Self, Peers, National Patient Level Data Ability to Drive Intervention Data Transparency (OH) Identify High Performers Identify Similar Practices to Collaborate With

Enhanced Accountable Payment Attribution Prospective & Agreed Physician Level Incentivization Standardized Payer Reporting Integrated, Aligned or Standardized Payer Relationships (OK) Moving Past Competitive Approach

https://innovation. cms https://innovation.cms.gov/initiatives/Comprehensive-Primary-Care-Initiative/index.html

Evaluating the Impact of Change A Quantified Approach Cost=Quality=Experience= Satisfaction? Per Capita Costs An inverse relationship to desired outcomes Quality of Care A definitional battle of metrics Patient Experience Moving beyond “satisfaction” Provider/Staff Satisfaction An eye to sustainability

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