As a result of the success of CPC, CMS launched a second phase of the program in 2017, Comprehensive Primary Care Plus (CPC+). CPC+ is a five-year initiative comprising 14 regions nationally and more than 3,000 practices. Neeraj Tayal, MD, Division of General Internal Medicine, and Mary Jo Welker, MD, Department of Family Medicine and their respective teams are leading the CPC+ program on behalf of The Ohio State University Wexner Medical Center.
A critical aspect to participating in CPC+ includes advancing these areas of focus:
Team-Based Care—Nurse case managers, clinical pharmacists, social workers, mental health specialists and nutritionists all play important roles in improving the health of patient and work in the medical center.
Care Management—The medical center applies a risk model to the population of patients these practices provide care for, to identify the sickest patients and the highest-cost patients. Once identified, staff work closely with them to develop care plans, and follow up more frequently.
Population-Based Intervention Tools—By increasing the use of electronic medical records, the medical center has improved analytics that allow staff to identify patients who have gaps in care, such as overdue colonoscopies and mammographies. This improves the organization's performance on quality metrics and the overall health of patients.
Mental Health Services—Individuals with depression and anxiety far outnumber psychiatrists. By hiring social workers who are trained in mental health care and collaborating with Ohio State's Department of Psychiatry and Behavioral Health, the medical center has developed a co-management model of care.
Alternatives to Office Visits—The medical center has built tele-health capabilities right into the electronic health record. After nearly a year of piloting this new functionality, it has been deployed to clinics, and doctors are incorporating this functionality into their practices. The medical center has also piloted video visits from some doctors' private offices, essentially providing an extra exam room and a convenient service to patients.