Comprehensive Primary Care (CPC)

The Right Care at the Right Time

Today’s tremendous focus on quality in health care is historic. Bonuses for doctors from payers based on quality measures means that for the first time, not only is quality important to patient outcomes, but it also impacts the economics of the medical office.

The Comprehensive Primary Care (CPC) initiative is 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 their work in the initiative. We are one of the seven regions selected to pilot this new way of paying for primary care – paying for keeping people well. Medicare, Ohio Medicaid and nine commercial insurance plans agreed to give 75 primary care practices a new source of revenue to use for preventive care and better patient management and coordination. We expect that this investment in primary care will pay off in fewer avoidable emergencies and hospitalizations, and our hope is that our results will change the way we as a country practice and pay for primary care.

Patient Centered Medical Homes (PCMH)

It has a title only a health care technocrat could have come up with, but “Patient-Centered Medical Home” (PCMH) refers to a level of care every patient should aspire to. Creating a PCMH is a way of running a primary care office where the doctor and staff reach out to the patients to make sure they get the care they need.

In a traditional practice, a patient gets care only when he or she initiates it by making an appointment. In a PCMH, the staff runs reports to see who is due for a checkup or screening, who is overdue for a prescription refill, who saw a specialist and what follow-up is needed. The office takes a proactive approach to keeping every patient as healthy as possible.

Benefits of a PCMH:
  • Stronger doctor/patient engagement
  • Better access to your doctor
  • Proactive intervention
  • Careful management of chronic conditions
  • Better medical outcomes
  • Fewer serious episodes
  • Less hospitalization
  • Better quality of life
  • Lower cost of health care for the patient (and by extension, the community)

We have worked with more than 80 practices to help them achieve their goals for attaining Patient-Centered Medical Home (PCMH) status and transform their practices in sustainable ways. Our system teaches a holistic approach that can be adapted to changing conditions.

Practice Development

Doctors go to school to learn how to treat patients, not to learn improvement science. The Health Collaborative is supporting the Comprehensive Primary Care initiative by helping the participating practices (doctors, nurses, and office staff) learn how to apply improvement techniques to the clinical setting:

  • Identify gaps in care
  • Develop change strategies
  • Establish consistent routines
  • Collect and measure data
  • Use I.T. to track progress

The goal is to assure that every patient visit results in the patient getting the right care at the right time, including the information and support needed to manage their condition after they leave the office.

We provide a constantly expanding library of tools and training systems created by our clinicians and improvement science specialists specifically for medical offices. These tools were designed to improve care, increase efficiency and integrate IT.