The Christ Hospital Physicians recently had more than 90 percent of its Primary Care practices selected to participate in the Comprehensive Primary Care Plus (CPC+) initiative, a partnership between payor partners from the Centers for Medicare & Medicaid Services (CMS), state Medicaid agencies, commercial health plans, self-insured businesses, and primary care providers.
Listen in as Joe Bateman, MD explains how TCHP is leveraging the CMS investment to develop a pcp infrastructure to transition to a new model of care and succeed in the changing environment.
Selected Podcast
New Care Model: Comprehensive Primary Care Plus (CPC+)
Featured Speaker:
Joe Bateman, MD
Joe Bateman, MD is a Primary Care Physician with The Christ Hospital Health Network. Transcription:
New Care Model: Comprehensive Primary Care Plus (CPC+)
Melanie Cole (Host): The Christ Hospital physicians recently had more than 90% of its primary care practices selected to participate in the comprehensive primary care plus initiative. A partnership between payer partners from the centers for Medicare and medicaid services, state medicaid agencies, commercial health plans, self-insured businesses, and primary care providers. My guest today is Dr. Joe Bateman, he’s a primary care physician with the Christ Hospital Health Network. Welcome to the show, Dr. Bateman, tell us a little bit about the evolution of primary care. What do you do in your office? And what is the CPC plus initiative?
Dr. Joe Bateman (Guest): Thank you very much for having me, Melanie. The evolution of primary care is going through a rapid transformation over the last five to ten years. The traditional primary care practice, as you know, has functioned much in the way that all of us have experienced getting healthcare, and that is patients call into the office, make appointments, and then go and see their primary care providers to address their healthcare needs. What we’ve realized is that model has some problems with it, and that unless patients are reaching out to the practice, making an appointment and seeing their physician, their healthcare needs may go unmet.
The model of one provider, one patient in an exam room, in order to deliver necessary healthcare services, is in reality insufficient to meet the needs of a patient population. As a primary care provider, we need to think beyond the four walls of the office, and to try and develop programs and processes that allow us to do outreach to our patients who aren’t coming to see us, in order to help manage their healthcare needs, and make sure that any gaps in their care are taken care of. So, that we get better overall outcomes.
Melanie: And is this also considered part of the medical home initiative? Are you creating that environment? So, that patients will then in the future feel more comfortable and confident, calling you ahead of time, as well as that outreach.
Dr. Bateman: Yes, the evolution of this particular project, and the transformation of primary care. The routes can be traced back to the patient's centered medical home model, that was first put forth by the American Academy of Pediatrics, and has since been adopted by the American Academy of Family Medicine, and also the American College of Physicians.
So, really pediatrics, family medicine, and internal medicine are fully supportive of the patient centered medical home model. And really the comprehensive primary care plus project is a further evolution of patient centered medical home. We call it patient centered medical home on steroids, to be honest with you because it’s much more robust, and it’s much more standardized, in terms of the milestones that one has to meet, as a practice in the project. And the outcomes that we must achieve, in order to be judged as successful, and achieving our quadruple aim in the project.
Melanie: So, what sort of adjustments have your primary care offices made due to these initiatives? What might patients and other providers notice?
Dr. Bateman: So, the first tenant of the project is to do… they are establish resources in the primary care practice to make the delivery of care more team-based, so that we can have financial resources, in order to build infrastructure, such as hiring our end care managers in the practices, as well care coordinators, who are usually at an MA or LPN level of licensure to help us manage those patients who really need additional resources. Those resources don’t need to be applied in large part to a younger, healthier population, but those most in need, usually older patients with chronic medical needs, need more attention than they can get during an average office visit. And need more points of contact in between those visits.
Melanie: Dr. Bateman, how is TCHP leveraging the CMS investment, to develop a PCP infrastructure to transition to a new model of care, and succeed in the changing environment?
Dr. Bateman: So, the investment gets leveraged not only in personnel, such as the care managers and care coordinators, which are additional resources, but also we’re trying to leverage our technology in the use of the electronic medical record to identify those patients most at risk, and begin the outreach process, proactively rather than waiting for them to contact us. So, they will notice from our EMR, we’re able to establish the patient portal. They will notice more proactive communication to them, they will notice more telephone contact with them, in order for us to stay in touch with them and encourage them to access services. The project also really focuses on engaging patients, rather than them being passive recipients of medical advice and information, but really to change the way that we interact with our patients in trying to get them engaged in their healthcare decision-making. And also, get them engaged, in what we refer to as self-management of their conditions. So, really an involving patient physician relationship, patient, physician interaction is, I think a really good benefit of the project.
Melanie: So, then speak about some of the clinical areas that the initiative aims to improve, as far as lower cost, better care, and you spoke about provider and being your own best health advocate, which is certainly important for patients, but what about having that engaged provider, and that relationship that you develop with the patients. So, speak about some of these clinical areas.
Dr. Bateman: Right, so we really focus on the high-risk populations of patients who have serious chronic medical illness, and are either not controlling their conditions adequately, and or are accessing healthcare services, such as frequent emergency room visits, or frequent admission and readmission to the hospital.
So, we have focused a lot of effort on patients with diabetes, patients with COPD, CHF, and we’re moving into other high-risk populations, as we assess things such as, social determinants of healthcare. So, the care managers that are working side-by-side with the physicians on a new… in a model that we call team-based care, work together to… first you have to identify those patients, and second you have to together develop interventions to try to improve the condition and the outcomes for those patients.
Melanie: It’s such an interesting initiative, Dr. Bateman, wrap it up for us with your best advice, and in summary, please let other physicians know what you would like them to know about this whole initiative, and the CPC+, and why other providers might be interested in this particular initiative.
Dr. Bateman: I think that when first presented with a project that will challenge the current model of care in a traditional primary care practices, the physicians may be somewhat hesitant to change their practice style, their practice model. I think if you talk to those of us who have been in the project now for four years or moving into the next five-year phase of the project, I do believe most if not all of the physicians would agree that having the additional resources, and having a healthcare team mean better outcomes for patients, and better care especially for those most at risk. Initially, the physicians tend to see it as just more work and more hassle for them, while they’re trying to barely get through a day that is maximally packed with work, but in the end, I think a little bit of taking a step back. Examining how you practice as a doctor, and looking at the basic tenants of the project, and supporting it in your practice. I think will lead to better care for patients, and a better practice environment for primary care physicians.
Melanie: Thank you so much, Dr. Bateman, for being with us today. You’re listening to Expert Insights, physician views and news with the Christ Hospital Health Network. More information on Dr. Bateman, and all of the Christ Hospital physicians is available at, TCHPConnect.org, that’s TCHPConnect.org. This is Melanie Cole, thanks so much for listening.
New Care Model: Comprehensive Primary Care Plus (CPC+)
Melanie Cole (Host): The Christ Hospital physicians recently had more than 90% of its primary care practices selected to participate in the comprehensive primary care plus initiative. A partnership between payer partners from the centers for Medicare and medicaid services, state medicaid agencies, commercial health plans, self-insured businesses, and primary care providers. My guest today is Dr. Joe Bateman, he’s a primary care physician with the Christ Hospital Health Network. Welcome to the show, Dr. Bateman, tell us a little bit about the evolution of primary care. What do you do in your office? And what is the CPC plus initiative?
Dr. Joe Bateman (Guest): Thank you very much for having me, Melanie. The evolution of primary care is going through a rapid transformation over the last five to ten years. The traditional primary care practice, as you know, has functioned much in the way that all of us have experienced getting healthcare, and that is patients call into the office, make appointments, and then go and see their primary care providers to address their healthcare needs. What we’ve realized is that model has some problems with it, and that unless patients are reaching out to the practice, making an appointment and seeing their physician, their healthcare needs may go unmet.
The model of one provider, one patient in an exam room, in order to deliver necessary healthcare services, is in reality insufficient to meet the needs of a patient population. As a primary care provider, we need to think beyond the four walls of the office, and to try and develop programs and processes that allow us to do outreach to our patients who aren’t coming to see us, in order to help manage their healthcare needs, and make sure that any gaps in their care are taken care of. So, that we get better overall outcomes.
Melanie: And is this also considered part of the medical home initiative? Are you creating that environment? So, that patients will then in the future feel more comfortable and confident, calling you ahead of time, as well as that outreach.
Dr. Bateman: Yes, the evolution of this particular project, and the transformation of primary care. The routes can be traced back to the patient's centered medical home model, that was first put forth by the American Academy of Pediatrics, and has since been adopted by the American Academy of Family Medicine, and also the American College of Physicians.
So, really pediatrics, family medicine, and internal medicine are fully supportive of the patient centered medical home model. And really the comprehensive primary care plus project is a further evolution of patient centered medical home. We call it patient centered medical home on steroids, to be honest with you because it’s much more robust, and it’s much more standardized, in terms of the milestones that one has to meet, as a practice in the project. And the outcomes that we must achieve, in order to be judged as successful, and achieving our quadruple aim in the project.
Melanie: So, what sort of adjustments have your primary care offices made due to these initiatives? What might patients and other providers notice?
Dr. Bateman: So, the first tenant of the project is to do… they are establish resources in the primary care practice to make the delivery of care more team-based, so that we can have financial resources, in order to build infrastructure, such as hiring our end care managers in the practices, as well care coordinators, who are usually at an MA or LPN level of licensure to help us manage those patients who really need additional resources. Those resources don’t need to be applied in large part to a younger, healthier population, but those most in need, usually older patients with chronic medical needs, need more attention than they can get during an average office visit. And need more points of contact in between those visits.
Melanie: Dr. Bateman, how is TCHP leveraging the CMS investment, to develop a PCP infrastructure to transition to a new model of care, and succeed in the changing environment?
Dr. Bateman: So, the investment gets leveraged not only in personnel, such as the care managers and care coordinators, which are additional resources, but also we’re trying to leverage our technology in the use of the electronic medical record to identify those patients most at risk, and begin the outreach process, proactively rather than waiting for them to contact us. So, they will notice from our EMR, we’re able to establish the patient portal. They will notice more proactive communication to them, they will notice more telephone contact with them, in order for us to stay in touch with them and encourage them to access services. The project also really focuses on engaging patients, rather than them being passive recipients of medical advice and information, but really to change the way that we interact with our patients in trying to get them engaged in their healthcare decision-making. And also, get them engaged, in what we refer to as self-management of their conditions. So, really an involving patient physician relationship, patient, physician interaction is, I think a really good benefit of the project.
Melanie: So, then speak about some of the clinical areas that the initiative aims to improve, as far as lower cost, better care, and you spoke about provider and being your own best health advocate, which is certainly important for patients, but what about having that engaged provider, and that relationship that you develop with the patients. So, speak about some of these clinical areas.
Dr. Bateman: Right, so we really focus on the high-risk populations of patients who have serious chronic medical illness, and are either not controlling their conditions adequately, and or are accessing healthcare services, such as frequent emergency room visits, or frequent admission and readmission to the hospital.
So, we have focused a lot of effort on patients with diabetes, patients with COPD, CHF, and we’re moving into other high-risk populations, as we assess things such as, social determinants of healthcare. So, the care managers that are working side-by-side with the physicians on a new… in a model that we call team-based care, work together to… first you have to identify those patients, and second you have to together develop interventions to try to improve the condition and the outcomes for those patients.
Melanie: It’s such an interesting initiative, Dr. Bateman, wrap it up for us with your best advice, and in summary, please let other physicians know what you would like them to know about this whole initiative, and the CPC+, and why other providers might be interested in this particular initiative.
Dr. Bateman: I think that when first presented with a project that will challenge the current model of care in a traditional primary care practices, the physicians may be somewhat hesitant to change their practice style, their practice model. I think if you talk to those of us who have been in the project now for four years or moving into the next five-year phase of the project, I do believe most if not all of the physicians would agree that having the additional resources, and having a healthcare team mean better outcomes for patients, and better care especially for those most at risk. Initially, the physicians tend to see it as just more work and more hassle for them, while they’re trying to barely get through a day that is maximally packed with work, but in the end, I think a little bit of taking a step back. Examining how you practice as a doctor, and looking at the basic tenants of the project, and supporting it in your practice. I think will lead to better care for patients, and a better practice environment for primary care physicians.
Melanie: Thank you so much, Dr. Bateman, for being with us today. You’re listening to Expert Insights, physician views and news with the Christ Hospital Health Network. More information on Dr. Bateman, and all of the Christ Hospital physicians is available at, TCHPConnect.org, that’s TCHPConnect.org. This is Melanie Cole, thanks so much for listening.