The Health Collaborative hosts nearly 350 healthcare professionals at CPC OH/KY Learning Session

By Kelly AardemaQuality Improvement Coordinator

On Friday, May 20, nearly 350 regional medical professionals and stakeholders filled the banquet hall of the Manor House in Mason, Ohio for a Comprehensive Primary Care (CPC) learning session.

The CPC program is a four-year demonstration project designed by the Centers for Medicaid and Medicare Services (CMS) Innovation Center to test the impact of enhanced primary care support and payment reform on health outcomes and overall cost of care. In 2012, The Health Collaborative was chosen to facilitate technical assistance for 75 local primary care practices participating in the CPC project in Greater Cincinnati. Greater Cincinnati is one of only seven regions across the country selected to participate in the Centers for Medicare & Medicaid Services (CMS) initiative, and is the nation’s largest demonstration site with 220,000 patients. The initiative brings Medicare together with 8 commercial and state health insurance plans to provide the practices with funding for preventive care and more coordinated chronic disease management, with the expected outcomes of fewer avoidable emergencies and hospitalizations.

CPC Champions

The discussion themes of Friday’s learning session focused around data-driven improvements, best practices for team-based care, and actionable strategies for connecting the medical neighborhood. The learning session featured important learnings from three and a half years of work focused on improving patient outcomes.

The day-long event kicked off with a presentation of the ‘CPC Champions’ award to PriMed Physicians Vandalia Family Practice, nominated by peers in honor of their exemplary work and leadership throughout the CPC program. Drs. Mark Couch and Julio Soto accepted the award and briefly reflected on their journey through practice transformation. “We felt that together, with like-minded people, we could create something on a scale that was previously unachievable. We are seeing results, feeling proud of our contributions, and like each of you, we believe that we can make healthcare better and are willing to work hard to make it happen.”

Morning breakout sessions examined successful approaches for using data to inform care, boost team engagement through change, and connect with beneficial resources in the community. These were followed by afternoon breakouts showcasing the value of strong, interdisciplinary care teams, with themes around robust leadership engagement, behavioral health integration, and evidence-based medication management.

Proven track record

These themes support the expected outcomes of the CPC program, including reductions in overall healthcare expenditures as a result of improved care delivery and lower rates of avoidable hospital admissions, readmissions, and emergency room visits.
And so far, that’s exactly what is happening.

From Nov. 2012 to Sept. 2015, our region has demonstrated great improvements in the following outcomes for Medicare beneficiaries, arguably some of the highest risk patients in the initiative.

• 9% reduction in overall hospital admissions
• 7% reduction in primary care treatable admissions
• 6% reduction in readmissions

“These results are evidence that our region is invested in finding new and innovate ways to deliver healthcare with a focus on the best possible outcomes for the patient. In turn, this reduces our region’s healthcare spending,” said Dr. Richard Shonk, Medical Director at The Health Collaborative.

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“Moreover, the level of engagement we’ve seen throughout these learning sessions is a strong testament to the commitment of our region’s healthcare providers to making measurable and sustaining changes to the way care is provided.”

Federal and state representatives were in attendance at the Learning Session, and commented optimistically about new opportunities that would promote the sustainability of practice transformation in our region.

Providers attribute these outcomes in part to the integration of dedicated care management staff working to enhance proactive support for high-risk patients and using a variety of data sources to guide improvement.

For the Providence Medical Group in Dayton, Ohio that means keeping the entire care team up to speed on the measured outcomes. “We report out weekly and monthly to our staff on the areas we’re trying to improve – ER visits, overall usage rates, and clinical quality scores. It’s a continued process improvement so that we identify issues before they become big problems,” said Larry Ratcliff, M.D.

Greater Cincinnati poised as a model community
Another area many providers attribute to the success of the CPC initiative is a focus on team-based care and engaging staff in a positive care environment.

“Our care coordinator through the CPC initiative is our change agent. Facilitating communication amongst staff, bringing in new ideas and best practices relative to CPC, and catalyzing resources around shared goals have enabled us to quickly improve our outcomes around care transitions,” said Ratcliff.

While this 4-year initiative wraps up at the end of 2016, CMMI has recently announced CPC+ that builds on the foundation that CPC created. And as the nation looks to this program to inform future Medicare and Medicaid policy, these early successes position Greater Cincinnati as a model for improved care, lower healthcare spending, and ultimately better health for our community.