AFM Selected for New Medicare Initiative

Announcement: Associates in Family Medicine is honored to have been selected by the Center for Medicare and Medicaid Services as a participating practice location for the Comprehensive Primary Care Initiative. The Comprehensive Primary Care (CPC) initiative is a multi-payer initiative fostering collaboration between public and private health care payers to strengthen primary care. Medicare will work with commercial and State health insurance plans and offer bonus payments to primary care doctors who better coordinate care for their patients.

We are excited and honored to be selected for this pilot project. This initiative will allow our physicians and support staff to significantly enhance patient care services. Family Physicians have long been in the forefront for their roles in coordination of care; however, reimbursement has always been limited to face to face encounters. This reimbursement model changes that dynamic as it provides funding to support a higher level of patient care coordination, and population management.

AFM is in the process of developing a healthcare coordination team. Initially the focus will be on reducing unnecessary emergency room visits and hospital stays, and most importantly we will focus on transitions of care. Patients are often in vulnerable situations during transitions of care. Extra effort put into orchestrating the patient’s recovery plan will reduce unnecessary expenses and improve clinical outcomes.

Our care coordination team will also work with local organizations to effectively utilize existing community resources. Care coordination is often a highly complex process that involves many different agencies and services. A community based care coordination team is already in place as part of a Medicaid pilot, and our practice will work closely with that team for complex high risk patients.”

AFM has a dedicated team working on forming a Patient Centered Medical Home. AFM is in the final stages of submitting an application to the National Committee for Quality Assurance for formal recognition as a Patient Centered Medical Home. Part of patient care coordination will be working with local specialty physicians on forming a medical community devoted to working even more closely together to provide high quality, cost effective, care.

Backgroud Details from CMS Website:

Primary care is critical to promoting health, improving care, and reducing overall system costs, but it has been historically under-funded and under-valued in the United States. Without a significant enough investment across multiple payers, independent health plans— covering only their own members and offering support only for their segment of the total practice population— cannot provide enough resources to transform entire primary care practices and make expanded services available to all patients served by those practices.

A primary care practice is a key point of contact for patients’ health care needs. In recent years, new ways have emerged to strengthen primary care by improving care coordination, making it easier for clinicians to work together, and helping clinicians spend more time with their patients. All around the country, health care providers and health plans have taken the lead in investing in primary care. Employers across the country have found that with health coverage policies that emphasize primary care, coordinated care, and other strategies that keep their employees healthy, they not only support a healthier workforce, they create a healthier bottom line.

The Comprehensive Primary Care Initiative will build on these and other efforts.

Initiative Details

The CPC initiative offers a way to break through this historical impasse by inviting payers to join with Medicare in investing in primary care in 5-7 selected localities across the country. The resources will help doctors work with patients to ensure they:

  • Manage Care for Patients with High Health Care Needs:Patient with serious or multiple medical conditions need more support to ensure they are getting the medical care and/or medications they need. Participating primary care practices will deliver intensive care management for these patients with high needs. By engaging patients, primary care providers can create a plan of care that uniquely fits each patient’s individual circumstances and values.
  • Ensure Access to Care:Because health care needs and emergencies are not restricted to office operating hours, primary care practices must be accessible to patients 24/7 and be able to utilize patient data tools to give real-time, personal health care information to patients in need.
  • Deliver Preventive Care:Primary care practices will be able to proactively assess their patients to determine their needs and provide appropriate and timely preventive care.
  • Engage Patients and Caregivers:Primary care practices will have the ability to engage patients and their families in active participation in their care.
  • Coordinate Care Across the Medical Neighborhood:Primary care is the first point of contact for many patients, and takes the lead in coordinating care as the center of patients’ experiences with medical care. Under this initiative, primary care doctors and nurses will work together and with a patient’s other health care providers and the patient to make decisions as a team. Access to and meaningful use of electronic health records should be used to support these efforts.