The Centers for Medicaid and Medicare Services, as well as several payer groups, invested in the Comprehensive Primary Care (CPC) Initiative to drive change and prepare organizations for population health management. The four year pilot program (2013-2016) required participating clinics to achieve several milestones which included: 1) Empanelment, Risk Stratification, and Complex Care Management; 2) Access and Continuity of Care; 3) Patient Experience; 4) Quality Improvement measured by achieving CQM benchmarks; 5) Care Coordination between the ED, Hospital; and 6) Shared Decision Making. Five hundred clinics across 7 states embarked on the journey. Better Patient Health, Better Care and Decreased Costs were realized. CMS is now funding the largest initiative to date based on the CPC framework, called CPC+ beginning in January 2017. CPC+ will include 5,000 clinics across 20 states.

Mercy Family Medicine, a 3 location clinic, serves over 17,000 patients with 20 providers. The clinic developed a risk stratification tool that captures the top 1% of the sickest patients, requiring complex care management. RN Care Coordinators care manage this population along with Behavioral Health care management. The clinic has demonstrated a reduced ED admission rate; decreased hospitalization for any cause for ACSC; and the 10th lowest Medicare (PMPM) expenditures compared to the other 75 CPC clinics in Colorado. In addition, the clinic developed a workflow for continuity of care to be established at the time of discharge from the ED and Hospital, which greatly influenced the positive outcomes.

Lessons learned were: 1) Identify your highest risk population through objective data and real-time subjective data. This is far more accurate than looking at claims based data. 2) Targeted complex care management of that highest risk population. 3) Care Management of that highest risk population additionally requires Behavioral Health Care Management 4) Care Coordination for ED and Hospital discharges is critical for decreased hospitalization and ED visits. These strategies lead to the realization of the Triple Aim.