5 requirements of CPC+: Planned care and population health

This blog is the fifth 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 preparations as you gear up for a 2021 or 2022 implementation. CPC+ was one of the models examined and was a foundation for creating the PCF.

Missed the first couple of blogs in our CPC+ series? Review how well you’ve been meeting access and continuity (function 1) here, care management (function 2), comprehensiveness and coordination (function 3) here and patient and caregiver engagement (function 4) here.

Track 1

Remember the days when providers would see a patient, treat that patient and then go on to the next one? Paper charts, no electronics…this is the office of the past. Now, we see technology everywhere and although it may feel as if it’s complicating your life, if used correctly it can greatly enhance your patient care.

Function 5 is all about using data to improve your population’s health. There are two major ways examining data can help your practice ― improve health and decrease costs. We will examine both.

Decrease costs

Payment models are increasingly moving towards value. This means that instead of being paid for each individual service, the outcomes you help your patients achieve are what brings in money. Using EHR analytics, you should look for unnecessary care that is provided.

Data analysis can also help identify certain patient populations that are at high risk for specific diseases, to enable you to correctly allocate personnel and resources. For example, identifying your patients who are likely to develop type II diabetes gives you the opportunity to refer them to programs to try to prevent it. By using a risk assessment tool, you can weight factors such as age, ethnicity, weight, first-degree relative with type 2 diabetes, low birthweight and sedentary lifestyle to identify patients who are at a higher risk.

Also certain comorbidities (e.g. cardiovascular and cerebrovascular disease, polycystic ovary syndrome, a history of gestational diabetes and mental health problems) can be included as possible risk factors since they increase chances of type II diabetes.

If enough of your patients fit a certain classification, it may make sense to create a program in house to help them (for instance, a diet and exercise program for those high-risk type II diabetes patients).

Improve health

Identifying your patient population at high risk empowers you to focus on ways to manage and mitigate that risk. But you need to be constantly reviewing your patient data for early intervention to work. It will enable the groups in your practice that need the most care; by identifying them, you can ensure you’re allocating enough resources to them.

Your highest-needs patients may benefit from dedicated time with a healthcare professional to review all of the medications they are taking. RxLive can take that off your plate and provide in-depth medication reviews with your high-risk patients at no cost to your practice. If interested, call 866.234.4974 to learn more. 

One way to measure the quality of the healthcare you’re providing utilizes electronic quality clinical measures (eCQMs). Capturing this data gives you real-time information for quality improvement and clinical decision support.

To make the most of using eCQMs, you need to consistently review the data. Questions to ask yourself include which eCQMs do you measure? Are there others that may be more beneficial for your practice? How often do you examine your population health eCQM data?

Yes, it may be time-intensive to set up new reports, but the insights gleaned from the data can greatly help your practice and your patients. Once you get into a good cadence of running the reports and examining the data, you’ll find that the benefits far outweigh the initial costs.

What’s different with Track 2?

The short answer is nothing. In past years, you were required to conduct care team meetings to review data, but that’s no longer a requirement since 2019. However, if you stopped those care team meetings, we’d suggest there’s value in revisiting why they didn’t work. It might make sense for you to reinstate them, but on a slower cadence (such as monthly). The main point of the care team meetings is to have a dedicated time to review the data and talk about new initiatives. When you don’t have a reoccuring time set aside to do that, the insights gained from this discussion can be lost in the shuffle of day-to-day care delivery.

Challenge your team to glean insights from examining the data. By empowering your care team to not only discover areas of improvement, but help come up with ways to improve them, you’re able to leverage the power of groupthink and keep your staff engaged. The process of discovering the solution can then become just as important as the answer itself.

Data can be a pain to collect, but without it you lose valuable insight about your patient population. The questions below should help you reassess how your data collection is going and if you need to adjust anything as you enter the final years of the CPC+ program.

Recap: Questions to ask yourself

  1. What data are you currently pulling to improve your population health?
  2. How often are you running these reports?
  3. What is your workflow after examining the data to implement changes to your practice?
  4. Is there other data you wished you had access to and, if so, how do you think you could get it?

Specific to eCQM

  1. Which eCQMs do you track?
  2. Are there any others that might affect your patient population more that you aren’t currently examining?
  3. How often do you examine population health eCQM data?
  4. Is your logic correct for all of your eCQMs? When was the last time you checked it for accuracy?
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.