Care Delivery Requirements for Program Year 2
October 20, 2017
Written by Kristen Schuster, Practice Facilitator
CMS had several announcements and changes for 2018 during the week of October 16th.
The practice point of contact was sent an important email on October 16th. This email included:
1) The Amended and Restated CPC+ Participation Agreement (PA)
2) Amended and Restated PA Guidance
3) Program Year (PY) 2 Care Delivery Requirement Guidance
If the appropriate person did not receive this email, log in to the CMS portal and identify the main point of contact that was on the PA. If you are still unable to locate the email with the attachments contact Telligen support. The signed PA for PY 2 is due December 1st, 2017.
CMS also announced changes to the Care Delivery Requirements for PY 2. Please note the changes by Track listed below.
Track 1 Changes
Access and Continuity (1)
- 1.3– Measure continuity of care for empaneled patients by practitioners and/or care teams in the practice.
Care Management (2)
- 2.1– Use a two-step risk stratification process for all empaneled patients, addressing medical need, behavioral diagnoses, and health-related social needs.
- 2.2– Based on risk stratification provide longitudinal care management.
Comprehensiveness and Coordination (3)
- 3.1– Enact collaborative care agreements with at least two groups of specialists identified based on the analysis of CMS and other payer reports.
- 3.3– Develop a plan for implementation of at least one option from a menu of options for integrating behavioral health into care, based on an assessment of practice capability and population need.
Patient and Caregiver Engagement (4)
- 4.1– Convene a Patient and Family Advisory Council (PFAC) at least three times in Program Year 2, and integrate recommendations into care and quality improvement activities as appropriate.
- 4.2– Implement self-management support for at least three high-risk conditions.
Track 2 Changes
Access and Continuity (1)
- 1.3– Measure continuity of care for empaneled patients by practitioners and/or care teams in the practice.
- 1.4– Regularly deliver care in at least one way that is an alternative to traditional office visit-based care.
Care Management (2)
- 2.1– Maintain a two-step risk stratification that takes in to account medical needs, behavioral health, a social needs:
- Step 1. Use an algorithm based on defined diagnoses, claims, or other electronic data allowing population-level stratification; and
- Step 2. Add the care team’s perception of risk to adjust the risk stratification of patients, as needed.
- 2.2– Based on risk stratification provide longitudinal care management.
- 2.3– For patients receiving longitudinal care management, use a plan of care containing at least patients’ goals, needs and self-management activities that can be routinely accessed and updated by the care team.
Comprehensiveness and Coordination (3)
- 3.3– Develop a plan to provide comprehensive medication management to patients discharged from the hospital and those receiving longitudinal care management.
- 3.5– Address psychosocial needs for high risk patients.
- 3.6– Develop practice capabilities to address the needs of a subpopulation of patients with complex needs that improves the quality of care and utilization.
Patient and Caregiver Engagement (4)
- 4.1– Convene a PFAC at least quarterly in Program Year 2, and integrate recommendations into care and quality improvement activities, as appropriate.
- 4.2– Identify and engage a subpopulation of patients and caregivers in advance care planning.
Reminder: Join Mountain-Pacific on October 31st from 12-1PM MST to discuss these changes for 2018.
Join Here: https://mpqhf.zoom.us/j/645861704
Call in: 1 646 558 8656
Meeting ID: 645 861 704
Also, please refer to CPC+ Connect to network with other CPC+ practices utilizing the same EHR for ideas and best practices. On the Plus Side is a weekly newsletter, emailed to all subscribers that lists upcoming educational events, CPC+ tasks and links to CMS resources. As always, complete CPC+ information from CMS can be found on the CPC+ Connect Portal. We encourage you to access the portal and check out all available CMS CPC+ resources.
If you have any questions, or run into issues with any of the CPC+ objectives and would like help please use the “Leave a Reply” section below, or email Kristen Schuster directly with your questions or comments.
Other Resource Links
CPC+ PY2 Care Delivery Requirements Guidance
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