Comprehensive Primary Care Plus (CPC +) Program
Track 2 Requirements
| Area of Focus | Objectives |
| Risk stratify patient population and identity/flag “Patients with Complex Needs” | 1. Enable the practice site to assign a risk score/label that reflects assignment based on the practice’s risk stratification methodology. 2. The methodology used to stratify practices should be clear and meet basic guidelines established by CMS. 3. The practice site practice team should be able to sort patients by score and update risk scores as needed. |
| Produce and display eCQM results at the practice level to support continuous feedback | 1. Enable the entire practice team to view eCQMs results at the practice site level to support continuous feedback on quality improvement efforts. 2. Measure results should be updated as frequently as possible so that measures reflect current progress. 3. This capability should present results in a usable, actionable manner that the care team can use to effectively manage population health. |
| Systematically assess patients’ psychosocial needs and inventory resources and supports to meet those needs | 1. Enable primary care practices to electronically assess patients’ psychosocial needs. 2. Enable primary care practices to capture or access electronically an inventory of resources and supports to meet patients’ identified psychosocial needs. 3. To support this objective practices must adopt certified health IT that meets the 2015 Edition criterion “Social, Behavioral and Psychological Data” found at 45 CFR 170.315(a)(15), within the first two years of the program |
| Document and track patient reported outcomes | CMS is evaluating a patient reported outcome survey instrument that will be sent to CPC+ Track 2 patients to identify specific care needs requiring intervention/management by the CPC+ practice site team. CMS plans to use the data collected from the patient-reported outcome survey to develop a patient-reported outcome performance measure that may be included in CPC+ measure set in the later years of the model. The modes of administration are yet to be determined. 1. The health IT tool should provide the care team with the ability to administer the survey, store and track patient responses, and score results longitudinally for each patient surveyed. 2. The practice should be able to review the patient responses/results in their EHR or other health IT tool and, as appropriate, establish care plans /interventions for positive findings. |
| Empanel patients to the practice site care team | 1.Enable the practice to assign each patient to a care team or practitioner and sort and review the patients by assignment. 2. The assigned provider should be visible in the patient record to members of the care team. |
| Establish a patient focused care plan to guide care management | CPC+ practices should utilize an IT-enabled, patient-centered care planning tool in order to support holistic care and a focus on beneficiary goals and preferences. 1. Enable providers to electronically capture the following care plan elements: • Advance directives and preferences for care • Patient health concerns, goals and self-management plans • Action plans for specific conditions • Interventions and health status evaluations and outcomes • Identified care gaps 3. The practice should have the ability to customize which of these elements are included within the care plan and how these elements are displayed. 4. Providers should be able to incorporate relevant triggers (e.g. a risk score or event) that indicate different care management actions. 5. The care plan tool should facilitate version control across care team members by capturing the date of the last review or change in plan and generating a scheduled date for reviewing and updating the plan. 6. Practices should be able to populate the care plan using data entered in the patient’s record (e.g. without duplicative data entry). 7. The care plan should be available to the patient on paper and electronically, and available in electronic format to care team members outside of the practice that are involved in the patient’s care. Care plan information should also be remotely accessible to practice team members delivering care outside of normal business hours. 8. To support this objective, practices must adopt certified health IT that meets the 2015 Edition “Care Plan” criterion found at 45 CFR 170.315(b)(9), within the first two years of the program |
| Optional: CPC+ practice site care delivery and documentation of the care touch documentation Please note: if vendor cannot support this functionality, the practice can still be in Track 2 as this is not mandatory HIT. | Current systems are designed for capturing office-based care encounters and payment. Presently, claims are used to understand which physicians are seeing a patient the most (i.e. attribution), what proportion of primary care services are provided at the assigned practice versus other practices, and other key parameters. However, as programs like CPC+ Track 2 encourage the use of non-visit-based services, providers as well as CMS will lose a key source of data for understanding primary care activity. As part of Track 2, CMS will work with vendors and providers to explore identifiers for non-visit-based care activities that will allow practices and the program to quantify the overall provision of care to the patient (such as emails, telehealth interactions, telephone encounters, text reminders, letters etc.). |