CPC+ is a national advanced primary care medical home model that aims to strengthen primary care through regionally-based, multi-payer payment reform and care delivery transformation. The goal of the initiative is to place the patient and caregiver at the center of care to achieve improved care, improved patient satisfaction and reduced cost. QHA works with 27 clinics in North Dakota to build a foundation for team-based care and assist them in the use of enhanced payment structures for continuous improvement driven by data and optimal use of HIT. 

The primary care functions that serve as a road map for care transformation under CPC+ are:

Access and Continuity

  • Patients are assigned to a primary care provider
  • Timely access to care
  • Alternate visit types (telemedicine, phone visits, group visits, etc.)

Care Management

  • Risk stratify the patient population
  • Provide longitudinal care management for high risk patients (ex. Diabetic patients)
  • Provide episodic care management (ex. patients discharged from the hospital)
  • Patient specific care plans

Comprehensiveness and Coordination

  • Document patient’s healthcare goals
  • Integrate behavioral health services
  • Monitor care transitions for patients that have been hospitalized
  • Establish relationships with community resources
  • Maintain collaborative care agreements with frequently used specialists

Patient and Caregiver Engagement

  • Establish a patient family advisory council (PFAC)
  • Integrate self-management support (promote collaboration between the care team, patient, and family)
  • Engage patients in shared decision making

Planned Care and Population Health

  • Use team-based care involving the WHOLE team
  • Manage patients with chronic conditions
  • Utilize pre-visit planning for chronic patients
  • Use data sources to identify high priority patients
  • Enhance team resources (ex. Health coach, nutritionist, social worker, etc.)

This initiative is funded by the Centers for Medicare & Medicaid Services (CMS).