Connecting Care through Comprehensive Primary Care

Four years ago, in the early stages of the Affordable Care Act and the beginning of the shift from volume- to value-based reimbursement, Mercy Family Medicine in Durango, Colo., took a hard look at its future. The five-physician practice had just been acquired by the local hospital and was looking for the right practice model and payment structure for the future.

"We were looking at all aspects of healthcare, including the quality perspective, hospital operations, and reimbursement, as well as the landscape of integrating primary care with everything we do on the hospital side, not only to show quality, but also to reduce readmissions and all related factors," said Will McConnell, vice president of operations and outreach strategy, for Mercy Regional Medical Center.

After weighing possible participation in the Medicare Shared Savings Program, the practice instead looked at a new program from CMS called the Comprehensive Primary Care (CPC) Initiative. The four-year program aligns the federal agency with commercial and state payers in seven U.S. regions to offer population-based care management fees and shared-savings opportunities to participating practices around a core set of comprehensive primary care functions. Those include risk-stratified care management; access and continuity; planned care for chronic conditions and preventive care; patient and caregiver engagement; and coordination of care.

"In looking at the two programs [Medicare Shared Savings Program vs. CPC],
we decided that rather than wait for the final years and shared savings to kick in, we wanted to align ourselves with a pilot program that helped us establish the proper infrastructure, while trying to figure out how to actually deliver better care," said McConnell.

McConnell and Tamra Lavengood, CPC coordinator for Mercy Family Medicine and clinical performance coordinator for Centura Health Physician Group, both part of larger parent health system, Centura Health, will discuss their participation in the CPC initiative at the Health Information and Management Systems Society conference (HIMSS16) in Las Vegas, Nevada. Their session, "Comprehensive Primary Care: Our Success Story" is scheduled for Wed., March 2 at 10 a.m.

They recently spoke to Physicians Practice about the initial phases of the CPC Initiative and the importance of health IT in making the program work.

Physicians Practice: What role has IT played in the model's implementation and its success to date?

Tamra Lavengood: We would not have been able to have the success we had without health IT. There are definitely building blocks to start this process and a key aspect, even to become a Patient-Centered Medical Home [Mercy Family Medicine has a level 3 designation], is that you have to have all your patients empaneled to a provider - that's a daunting task.  We now have 22 providers, so you need to have that embedded in your EHR.

The second task we were assigned was to risk stratify all of our patients; identify all
of our high risk patients and identify what resources to put in place, how to care manage them, and establish where they are in their care management needs. So that was probably the second largest undertaking – to develop something that would integrate HIT. We really had some "a ha" moments, where … you not only have to look at things quantitatively - how many times were they in the hospital or the ER, how many medications do they have, etc. - but then just as important, you need to look at all the psychosocial determinants when patients come in and capture that.  Trying to identify how to do that [in our EHR] has been an exciting journey. Mercy Family Medicine is part of 145 clinics in Centura Health Physician Group (CHPG), which is … trying to incorporate a risk stratification methodology into their EHR, across the system.

Throughout the journey, we learned that patients who have complicated chronic illnesses can be effectively managed physically, but just as important there's the behavioral and emotional side that is 50 percent of managing patients. So to be able to document and share the behavioral health information we need to have an EHR that will incorporate a confidential area that can also be shared across systems.  Being able to identify how behavioral health can bill in collaboration with a primary care provider is just as crucial. 

We did not have all of those [components in our EHR] and moving forward, this is really what vendors need to be looking at: how to make it easy to empanel, risk stratify, and create care plans that are not complicated and can be easily accessed. Clinics need care plans that are living documents, a longitudinal care plan; and acute care plans that can go across the healthcare systems, with integration of behavioral health.

PP: What advice would you have for other practices considering the model?  What are some lessons learned you can share?

TL: It is extremely beneficial to evaluate the vendor and assess how willing they are to work with you when you see an area that needs to be changed or strengthened.  Vendors need to be willing to make adjustments and take an in depth look at the clinical side. I think that to be able to configure how to collect and track data - it takes such an analytical mind, but you've got to have that conversation on the front line. A lot of time there's a real disparity with that. So when an organization is moving forward, they need that collaborative relationship with their vendor.

Will McConnell: From an implementation standpoint, I think some of the keys are having the right people in the leadership roles. I know it is clich̩ and every single change management framework talks about "make sure you have the right people on board," but honestly, it's that plus giving them the ownership to do what needs to be done. Yes, we thought this would be a great idea and needed to take a few steps down the path to be far enough into it so people could see where it was going. Then having those right people lead it and take it and own it so that it is theirs Рit's coming from the clinic and not from an outside source; it is generated from their momentum and their desire to move it forward. It took a year, but once we hit that point, it became kind of a self-sustaining model and it was a lot more pull and a lot less push.