Comprehensive Primary Care Plus (CPC+)

Payment Reform, and the Right Care at the Right Time

The State of Ohio has set a goal to involve 80 to 90 percent of the state’s population in a value-based payment model within five years. We set the foundation for that goal in Comprehensive Primary Care (CPC) Classic, as one of only seven regions in the U.S. selected to pilot a new way of paying for primary care – paying to keep 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, as well as better patient management and coordination.

For 2017, CPC+ is considered an Advanced Alternative Payment Model under the new Medicare/Medicaid program.

Our success in the first phase has resulted in an expansion of this approach to the entire state of Ohio. We are the largest of the 14 regions in CPC+ with 562 total practices, including approximately 23 practices in Northern Kentucky, and 13 payers participating. As in CPC Classic, we expect that this investment in primary care will pay for itself through better health and fewer hospitalizations. The Health Collaborative team performs a dual role in CPC+: 1) as convener and learning collaborative under contract with Center for Medicare and Medicaid Services (CMS), and 2) as the organization designated by the payers to aggregate and report claims data to practices and plans. These two roles complement each other well, and the success of our region in CPC Classic can be directly attributed to them. Visit the CMS webpage for a general overview of CPC+.

CPC+ key drivers

Data Transparency

Better data = more informed decisions about health and healthcare. We gather clinical data and conduct surveys and studies that support quality improvement, facilitate shared learning, and provide valuable information used in planning healthcare delivery.

Five Core Functions

Our CPC+ team offers resources to help practices work with their patients to provide the following five comprehensive primary care functions:

1. Access and Continuity: Because health care needs and emergencies are not restricted to office operating hours, primary care practices optimize continuity and timely, 24/7 access to care guided by the medical record. Practices track continuity of care by provider or panel.

2. Planned Care for Chronic Conditions and Preventive Care: Participating primary care practices proactively assess their patients to determine their needs and provide appropriate and timely chronic and preventive care, including medication management and review. Providers develop a personalized plan of care for high-risk patients and use team-based approaches like the integration of behavioral health services into practices to meet patient needs efficiently.

3. Risk-Stratified Care Management: Patients with serious or multiple medical conditions need extra support to ensure they are getting the medical care and/or medications they need. Participating primary care practices empanel and risk stratify their whole practice population, and implement care management for these patients with high needs.

4. Patient and Caregiver Engagement: Primary care practices engage patients and their families in decision-making in all aspects of care, including improvements in the system of care. Practices integrate culturally competent self-management support and the use of decision aids for preference sensitive conditions into usual care.

5. Coordination of Care Across the Medical Neighborhood: Primary care is the first point of contact for many patients, and takes the lead in coordinating care as the center of patients’ experiences with medical care. Practices work closely with patients’ other health care providers, coordinating and managing care transitions, referrals, and information exchange.

Quality Improvement

Our team of Lean-certified quality improvement specialists possesses diverse clinical expertise, and is recognized nationally for its payment reform subject matter expertise. We have successfully supported 75 practices in transformation efforts to pursue patient-centered medical home certification through CPC Classic. Employing the Institute for Healthcare Improvement quality improvement model, we have facilitated quality improvement learning collaboratives across diverse healthcare settings.

 Meet the Team

  • Brian Kegley

    Brian Kegley, RN

    Data Analyst and hb/analytics Coach

    Brian Kegley combines clinical nursing and data analytics skills, along with experience leading multi-departmental teams.

  • Mary Maune

    Mary Maune

    Account Manager, Large Accounts

  • Sean Flynn

    Sean Flynn

    Senior Implementation and Product Specialist

  • Dr. Richard Shonk

    Dr. Richard Shonk

    Chief Medical Officer

    Dr. Shonk is a board-certified physician in Family Medicine, with a passion for overseeing clinical data collection & public reporting.

  • Dr. Barbara Tobias

    Dr. Barbara Tobias

    Chief Medical Officer

    Dr. Tobias is a family physician providing leadership & support to physicians & practices in public reporting, QI, and practice transformation.

  • Sara Bolton

    Sara Bolton

    Sr. Director, Programs and Services

    Sara has experience managing large-scale primary care transformations using innovative service delivery and payment models.

  • Tiffany Mattingly

    Tiffany Mattingly, RN

    Director, Clinical Quality Improvement

    Tiffany Mattingly has over 14 years’ clinical experience, leading projects sensitive to the complex dynamics of diverse healthcare settings.

  • Kate Haralson

    Kate Haralson

    Manager, Clinical Quality Improvement

    Kate has a strong background in national- and state-wide project management and quality improvement work. 

  • Meg Cone

    Meg Cone

    Lead CPC+ Practice Facilitator Coach

  • Kelly Aardema

    Kelly Aardema

    CPC+ Practice Facilitator Coach

    Kelly Aardema has 4 years’ experience as CPC learning faculty, and was instrumental in developing the curriculum for CPC Classic.

Resources & Assistance

Click here to read more about the CPC+ initiative on the CMS website. 

Click here to read The Health Collaborative’s press release about the Ohio-Kentucky region’s participation in CPC+.

To contact our team of CPC+ experts and practice facilitator coaches, please send an email to CPCplus@healthcollab.org

Upcoming Events

We have four statewide learning sessions each year: two are full-day, in-person events with expected attendance of over 900 people; and two are half-day events held virtually.

Attendees include representatives from CMS, the Lewin Group, health plans, and CPC+ primary care practices from around Ohio and Northern Kentucky. Our first in-person CPC+ Learning Session will be held in Columbus, OH on July 18, 2017. If interested in additional information, please contact Kate Haralson, Manager, Clinical Quality Improvement, at kharalson@healthcollab.org, or Tiffany Mattingly, Director, Clinical Quality Improvement, at tmattingly@healthcollab.org.

CPC Classic: Success Stories

CPC Classic stats