HealthTeamWorks has been on the frontlines of primary care transformation for more than 25 years. The 501(c)(3) nonprofit exists today to solve complex health care problems in the pursuit of health, equity, and resilience. This requires increasing successful Alternative Payment Model (APM) participation, fostering resilience in primary care, and bridging clinical, public health, and communities. HealthTeamWorks’ pronounced footprint in primary care transformation was most recently evidenced in the Independent Evaluation of Comprehensive Primary Care Plus (CPC+) Fourth Annual Report. HealthTeamWorks served as faculty on the CPC+ National Learning Network and facilitators in two Regional Learning Networks.
CPC+ was the largest, most ambitious primary care delivery and payment reform model tested in the United States. Launched in 2017 by the Centers for Medicare & Medicaid Services (CMS), the five-year program explored the hypothesis that practices could realize primary care delivery transformation by coalescing multipayer payment reform, actionable data, health IT support, and robust learning supports.
CPC+ included two primary care practice tracks with incrementally advanced care delivery requirements and payment options to meet the diverse needs of primary care practices in the United States. Through a unique public-private partnership with 61 aligned payers in 18 regions, the CPC+ payment redesign gave practices the additional financial resources and flexibility needed to make investments to improve quality of care and reduce the number of unnecessary services their patients received.
With help from the learning supports, such as the CPC+ Implementation Guide and direct practice coaching, which HealthTeamWorks co-authored and provided, respectively, CPC+ practices implemented change tactics related to five primary care functions by the end of the testing period in December 2021: access and continuity, care management, comprehensiveness and coordination, patient and caregiver coordination, and planned care and population health.
CPC+ Learning Supports rated high
One goal of the model was to help CPC+ practices achieve the triple aim – better health, better care, and smarter spending. HealthTeamWorks provided regional support to 187 designated CPC+ practices in Colorado and 35 in Nebraska to help them get there.
HealthTeamWorks’ roles included helping establish and manage the National Learning Network component of the Learning System for CPC+ and leading the Colorado and Nebraska Regional Learning Networks. The National Learning Network and Regional Learning Networks together comprised the full Learning System for CPC+. The CPC+ Learning System was designed to optimize performance of the CPC+ model by providing actionable data and effectively capturing and diffusing new knowledge among participating practices, payers (including CMS), and HIT vendors, and fully engage participating practices, payers, and other stakeholders in achieving the CPC+ aims.
When practices were asked to rate the usefulness of CPC+ learning supports, they scored high. In Program Years 2 through 4, about 90% of participants rated the learning supports as very useful or somewhat useful.
In another instance, CPC+ practices were asked about their perception of the [value] of various learning supports offered in Program Year 4. Among several learning supports, this rating included the CPC+ Implementation Guide HealthTeamWorks co-authored. 96% of practices indicated the Guide was very or somewhat useful. Telephone/virtual coaching also received a 92% utility rating.
Highly favored learning supports continue to propel practices forward
These learning supports resulted in improved performance measures, which led to performance-based incentive payment retention for CPC+ practices. Specifically, HealthTeamWorks provided practices with the following technical assistance:
- Team-based coaching strategies and workflows tailored to individual practice needs.
- Evidenced-based practices around Behavioral Health Integration (BHI) and best practices when onboarding BH clinicians
- BHI supports through community collaborations that address specific social determinants of health needs.
- Population health strategies to help practitioners better understand chronic conditions around patient health.
- Risk stratification coaching to identify patients for case management services and outreach especially for patients close to a chronic disease diagnosis.
- Actionable data to improve utilization measures, quality outcomes, and patient engagement.
- Identification of gaps in specialty care and hospital discharges using actionable data.
- Alignment with payer contracts and CPC+ measures by combining payer results with Data Feedback Tool (DFT) results and payer data.
- Learning sessions that achieved high engagement and attendance.
HeathTeamWorks is also credited with creating a trusted and positive rapport with CPC+ stakeholders and co-facilitators who participated in well-attended learning sessions, national poster presentations, Practices in Action calls, Regional Implementation Networking Group convenings, and cross-regional coaching calls.
HealthTeamWorks remains on the frontlines of Primary Care Transformation
HealthTeamWorks offers a robust suite of facilitated training and technical assistance that includes live, virtual, and on-demand offerings. Backed by a renowned practice transformation team with decades of proven successes, HealthTeamWorks continues to help practices transition to value-based APMs; transforming practices and systems by optimizing care teams and reducing turnover; integrating behavioral health in primary care; aligning strategic and business planning; facilitating quality improvements to help organizations manage change; and elevating diversity, health equity, and inclusion to foster cultural humility and allyship, informed by social determinants of health.
To learn more, or to request support, visit HealthTeamWorks.org. Primary care practices and community-based organizations are also encouraged to sign up for a variety of free tools and resources designed to advance health care transformation.