5 requirements of CPC+: Care management (function 2)

This blog is the second in a five-part series that will help you review your current CPC+ implementation. Now that we’re 2 to 3 years into the program, you can review what has and hasn’t been working for your practice with the help of these guides.

For practices considering Primary Care First, this series can also be used for preparation as you gear up for a 2021 or 2022 implementation. CPC+ was one of the models examined when creating the PCF program.

Missed the first blog in our CPC+ series? Review how well you’ve been meeting access and continuity (function 1) requirements by reviewing it here.

Function 2: Care management

Function 2 is care management; however, to be more specific, it is care management of your most at-risk patients. Why is risk stratification so important? If you can properly identify the risk scores of all your patients, you can identify the population that has a high number of patients who need a certain level of care. By providing this care proactively, you can better optimize clinical outcomes, reduce costs and save money for both the practice and your patients. Risk stratification is at the core of value-based reimbursement.

Primary care typically serves a diverse patient population with diverse needs. A healthy millennial coming in for his yearly physical shouldn’t be treated the same as a baby boomer who sees multiple specialists. All practices should take the time to identify their patient population and map out individualized plans for patients who need the most care, but that takes time. As a CPC+ organization, you’re now paid extra to take the time to do this.

Risk strategization key foundation for the human touch

The first step is ensuring your risk stratification is correct. You should be able to analyze your patient data to identify the high-risk groups and then plan and execute a care plan accordingly. 2018 Program Year 2 Requirements spell it out a little more explicitly by stating that you need to “use an algorithm based on defined diagnoses, claims, or other electronic data allowing population-level stratification.” Then step 2 is essentially to use the human touch to double-check the patient designations.

At this point, your risk stratification is complete. However, you want to ensure that every so often, you reexamine the data and make sure that some of your patients haven’t shifted tiers. People’s health and environmental factors aren’t static, so your risk stratification shouldn’t be either. So the question should be, “when’s the last time you risk-stratified your patient population?”

Care management post-ED or inpatient discharge

The second bucket of the care management function is care after Emergency Department visits or hospitalization. 2018 Program Year 1 and 2 Requirements state that patients with ED visits receive a follow-up interaction within one week of discharge. 75% of hospitalized patients in target hospitals are to be contacted within two business days. By 2019, this was relaxed to patients merely receiving “timely” follow-up. But this should still fall within the guidelines set before, if not even stricter now.

Timely follow up is key to preventing patients from costly readmittance. Questions to ask yourself include: on average, how soon do you follow up with a patient after an ED visit? On average, how soon do you contact patients who are hospitalized in target hospital(s)? If you want to dive even deeper, look into which patients went the longest without contact and try to determine why. Is there a break in the system that needs fixing?

What’s the difference if you’re Track 2?

With Track 2, the only difference in 2018 Program Year 1 and 2 requirements is the addition of plans for patients receiving longitudinal care management. Year 1 establishes the plan; year 2 requires that it’s routinely accessed and updated by the care team. It should now be part of your workflow to continually update these plans every time something changes with your patient’s care.

This is also a good time to reexamine the format of your longitudinal care plan. Is it easy to understand for the members of the care team as well as the patient? You need to remember that often what makes sense to a provider — whether formatting or language — can confuse a patient. It can be very helpful to ask patients themselves the last time they looked at their care plan and they find it easy to understand. A care plan is only useful if the patient can understand and act on the recommendations.

There’s no difference between Track 1 and Track 2 with 2019 requirements. However, since you’ve already established care plans for your increased-risk patients by this time, it should be easy to continue to update the plans and use them as an important foundation for new patients.

  1. On average, how soon do you follow up with a patient after an ED visit?
  2. On average, how soon do you contact patients who are hospitalized in target hospital(s)?

In addition, for Track 2 practices:

  1. How often are your care plans updated for patients receiving longitudinal care?
  2. Is there an easy way for every member of the care team who has access to update that plan?
  3. How often do your patients look at their care plans? Do they find it easy to understand?

Patients are often prescribed more medications during a hospital visit. One patient explained that he scheduled a consultation with an RxLive pharmacist after his hospital stay because he now had four more medications and was concerned. A medication review helped him reconcile all of the prescriptions he was taking. Providing medication reconciliation to patients following hospital admission/discharge/transfer and, as appropriate, following an ED discharge, was a requirement in 2018 Program Year 2 Requirements. This should still be seen as a best practice today that RxLive can help with.

Next blog: Evaluating success with function 3, comprehensiveness and coordination

Now that you’ve identified your high-risk patients, created plans to manage their care and have a system for timely follow-up after hospital and ED discharges, the next step is to coordinate care amongst everyone who has a hand in the well-being of your patients. In the next CPC+ blog, we’ll discuss the necessary relationships being forged across your network of providers to improve population health.

Kristen Engelen, PharmD
Kristen Engelen, PharmD, is the chief pharmacy officer of RxLive and a certified consultant pharmacist; she has over a decade of experience in retail pharmacy settings. Kristen became an RxLive co-founder because of her passion for geriatric pharmacy, with a focus on the intersection of pharmacy and aging.