1. Implementation of CPC+ in Multiple Residency Practices: Lessons Learned from the Field
Stacey Bartell MD, Jamila Taylor, MD
Lisa Simmons-Fields, RN, MSA,CCM, CPHQ
Diane Riddle, Quality Coordinator

2. Disclosures
None

3. Goals and Objectives
Define components of the CPC+ model of care delivery.
Ideas to take back to your practices for starting implementation of CPC+.
Strategies for involving residents and faculty in the use of data to evaluate practice transformation and drive the PDSA cycle. 

4. "Bring your whole self to work; not only your knowledge and expertise, but also your values. Stay true to who you are and have the courage of your convictions. If you do, you will become an authentic and courageous leader — something intensely needed at this time in healthcare. And you will have the power to change your workplace and the community around you." Mary Brainerd, HealthPartners

5. What is CPC+ ? Comprehensive Primary Care Plus
National Advanced Primary Care Medical Home Model  (APM)
Multi-payer payment reform
Transform Care Delivery

6. There are 2,850 primary care practices participating in Comprehensive Primary Care Plus (CPC+) Round 1, which began on January 1, 2017

7. Who are we? Ascension Health, St. John Providence Physician Network
Large multi-specialty network covering 5 counties in Michigan with ~500 physicians
Overall # of PCPs in the network - 255
33 CPC+ sites
122 PCPs
53 PCPs (FP/IM) are leading our residency practice programs
Track 1 – 24 practices (3 residency practices)
Track 2 – 9 practices (4 residency practices)
15,968 attributed Medicare FFS lives enrolled in CY17 4th

8. Starting Points Various stages of practice transformation
All practices BCBSM PCMH designation
4 practices had experience with MiPCT
5 Family Practice, 2 Internal Medicine
5 residency practices converted EMRs in February

10. 5 Comprehensive Primary Care Functions
1. Access and Continuity 2. Care Management 3. Comprehensiveness and Coordination 4. Patient and Caregiver Engagement 5. Planned Care and Population Health

11. Components of Performance-Based Measures and Incentives
eCQM (75%)
Utilization – (EDU 33%) (IHU 67%)
Patient experience of care (25%)

12. Starting Goals
Understanding HCC/RAF & frequently missed chronic conditions
Established shared goals / clear roles
Ensure process for ADT notification
Pre-visit planning, daily huddles
Centralized process for clinical and quality data
Schedule patients annual wellness visits
Create learning communities

13. Goals Empanelment Risk stratify all patients PFACS
Build a culture of quality
Educate on principles of team based models & practice education
Delegate authority via PCMH protocols
Provide data transparency
Establish practice care team meetings

14. 1. Access and Continuity
Empanel all patients to a practitioner or care team (95% goal)
Ensure patients to 24/7 access to physician with access to EMR
Optimize continuity
Offer alternative visits: home visits, group visits, virtual visits or visits at other location (Track 2)

15. High-Functioning Primary Care Residency Clinics
Building Block 3: Features of Empanelment • Patients are empaneled to faculty and residents. • Residents regularly review their panels. • Resident and faculty panel sizes are tracked and adjusted for level of need. ( ), ( ) • Clear process exists for reassigning panels when residents graduate.
aamc-ucsfprimarycareresidencyinnovationreport.

16. Lessons Learned Teach concept of empaneling and how to perform in EMR
Provide regularly feedback regarding status of empanelment
Evaluate continuity and panel size for each physician/resident level
Engage residents in home visits, NH visits, and group visits

17. 2. Care Management Track 1 - Risk stratify all empaneled patients
Track 2 - Requires two-step process
Step 1 Diagnoses
Step 2 adjust with care team practice
Refer to care management based on risk
Provide episodic and longitudinal care to patients
Provide care plans for all patients in longitudinal care management
Contact all ER discharges within 1 week
Contact 75% of hospital discharges within 48 hrs.

18. Implementation Strategies
AAFP tool for risk stratification – “clinical intuition”
Care plan guide
Transitional Care Management (TCM) visits
ER outreach and analysis

19. 3. Comprehensiveness and Coordination
Interact with Specialists
Track Hospital discharges, ADT feeds
Assess psychosocial needs and link to community services
Integrate Behavioral Health Services

20. Coordinate care with specialists
Identify high volume, high cost specialists
Develop Collaborative care agreements
Coordinate referrals
Track and close loop on all referrals
Share patient records across care settings
Improve ADT feeds

21. Community Linkages Screen patients with unmet social needs
Create and maintain an inventory of community organizations
Build relationships with community agencies
Track and measure success rate of linkages over time
Health-Leads-Screening-Toolkit-July-2016.pdf
AHRQ Health Literacy Universal Precautions Toolkit, 2nd Edition

22. Behavioral Health Integration

23. 4. Patient and Caregiver Engagement
Convene PFAC and integrate recommendations into care as able
Provide regular patient surveys
Facilitate self-management support
Engage patients in shared decision making

24. Best Practices Created PFAC toolkit
Developed Shared-Decision making tools
Engaged patients in feedback surveys - Phreesia
Integrated Self-Management tools - AAFP

25. 5. Planned Care and Population Health
Use payer or CMS feedback reports at least quarterly on 2 utilization measures and 3 eCQMs to develop strategies to improve population health
Track 2 - Conduct weekly care team meetings to review and improve data

26. Actual Quarterly Progress
CPC+ Performance Based Incentive Payment Quality and Utilization Benchmarks
Actual Quarterly Progress
CMS ID#
NQF#
Measure Title
Performance percentile Q1 Q2 Q3
Q4 as of 11/28/17
eCQMs
P30
P70
CMS165v5
0018
Controlling High BP
55.40%
71.01%
62%
76%
78%
79%
CMS122v5
0059
Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%)
35.90%
9.09%
50%
25%
23%
22%
CMS156v5
0022
Use of High-Risk Medications in the Elderly
21.22%
0.90%
CMS149v5
N/A
Dementia: Cognitive Assessment
17.57%
88.14%
16%
39%
56%
CMS139v5
0101
Falls: Screening for Future Fall Risk
17.93%
81.05%
64%
70%
77%
CMS137v5
0004
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
0.95%
5.13%
CMS50v5
Closing the Referral Loop: Receipt of Specialist Report
6.25%
36.96%
12%
18%
21%
CMS124v5
0032
Cervical Cancer Screening
15.09%
45.00%
40%
55%
57%
60%
CMS130v5
0034
Colorectal Cancer Screening
15.98%
56.20%
45%
63%
65%
67%
CMS131v5
0055
Diabetes: Eye Exam
80.69%
98.58%
14%
29%
51%
CMS138v5
0028
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
81.60%
94.68%
84%
95%
CMS166v6
0052
Use of Imaging Studies for Low Back Pain
90.48%
100.00%
100%
74%
72%
CMS125v5
2372
Breast Cancer Screening
22.22%
55.26%
48%
73%
CMS159v5
0710
Depression Remission at Twelve Months
Not Available
Utilization
P50
P80
Inpatient hospital utilization*
1.17
0.89
Emergency department utilization*
1.42
1.07
Your performance on Clinical Quality Measures (eCQMs) will determine the largest share of your CPC+ Performance-Based Incentive Payment (PBIP). To qualify for the PBIP, your practice must report 9 of 14 eCQMs in the CPC+ eCQM Measurement Set.
Risk Stratification - Every Encounter
4.99%
26.95%
47.27%
Complex Needs
0.04%
0.43%
2.78%

27. Develop Culture of Change
Start with defining your care team and expanding their roles
Review data (eCQMs & Quality Reports)
Develop PDSA cycles/workflows
Continuous improvement of processes (QI projects – residents led)
Regular meeting and education – (weekly, monthly, quarterly)
Celebrate successes with care team!!
Don’t forget the patients

28. Key Messages Identify resources for data analytics and reporting.
Create Quality Super-Users and identify the practice site Physician Champion.
Provide a multi-tiered approach to education
Resident Education

29. Resources CPC+ connect portal CPC+ groups CPC+ residency group
Regional learning Webinars and in person meetings
AAFP resources

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