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Strengthening Primary Care

 

The Comprehensive Primary Care (CPC) initiative was a four-year multi-payer initiative designed to strengthen primary care. Since CPC’s launch in October 2012, CMS has collaborated with commercial and State health insurance plans in seven U.S. regions to offer population-based care management fees and shared savings opportunities to participating primary care practices to support the provision of a core set of five “Comprehensive” primary care functions.

These five functions are:

  • Risk-stratified Care Management
  • Access and Continuity
  • Planned Care for Chronic Conditions and Preventive Care
  • Patient and Caregiver Engagement
  • Coordination of Care across the Medical Neighborhood

The initiative tested whether provision of these functions at each practice site — supported by multi-payer payment reform, the continuous use of data to guide improvement, and meaningful use of health information technology — can achieve improved care, better health for populations, and lower costs, and can inform future Medicare and Medicaid policy.

CPC serves as the foundation for Comprehensive Primary Care Plus (CPC+), a five-year advanced primary care medical home model launched in 14 regions in January 2017.

HealthTeamWorks' Role

During the CPC Initiative, HealthTeamWorks provided quality improvement coaches to 62 practices over the course of two years. HealthTeamWorks facilitated shared learning through learning collaboratives and on-site coaching support. Other components of the program included: data reporting and registry functionality, practice team redesign support, system and workflow redesign, advanced access, and practice culture. HealthTeamWorks also provided national technical assistance through facilitation of national webinars, EHR affinity groups and rapid cycle action groups.

  • Low Total Cost

    Low Total Cost

    COLORADO MULTI-STAKEHOLDER PCMH PILOT 

    Sought to increase communication between the patient & caregiver, and improve coordination of care within a medical neighborhood. Resulted in: 

  • High Quality

    High Quality

    HealthTeamWorks has demonstrated success in clinical quality improvement measures:

  • High Quality

    High Quality

    IMPROVEMENT IN CARDIOVASCULAR HEALTH IN COLORADO & NEW MEXICO 

    BP improvement 48

    HgbA1c >9 reduction by 28

    Tobacco use screening increase by 15

  • High Quality

    High Quality

    Reduction In Chronic Disease In Colorado

    Providing a comprehensive approach that focuses on prevention, early detection, and treatment. 

  • Provider & Team Vitality

    Provider & Team Vitality

  • Provider & Team Vitality

    Provider & Team Vitality

    Redesigned curricula to train physicians in the core competencies of PCMH care delivery resulting in...

    Population management measures
    Quality Improvement (QI) processes
    Continuity of Care
    Self-management Support follow-up
    Patient Centered Care
  • Low Total Cost

    Low Total Cost

  • Provider & Team Vitality

    Provider & Team Vitality

    Improvements In Leadership & Staff Engagement Measures

  • Patient Experience

    Patient Experience

    HealthTeamWorks Supported CPC practices reported 

    of patients getting timely appointments, care and information

  • Low Total Cost

    Low Total Cost

  • High Quality

    High Quality

    Pediatric Measures Improved Across The Board

  • Low Total Cost

    Low Total Cost

    Colorado All-Payer Claims Database showed the Total Cost of Care for the 3 largest PCP Practices in a Denver Metro independent practice association (IPA):

    "cost savings"

Project Details

Location

Statewide, CO
United States

Duration
2012-2016