1. Russell Kohl, MD, FAAFP Medical Director TMF Health Quality Institute
What Works in PCMH Preliminary Lessons from the Comprehensive Primary Care Initiative
Russell Kohl, MD, FAAFP
Medical Director
TMF Health Quality Institute

2. Preliminary Learnings
Outcomes of Year 2 Initial Analysis
These results suggest that a data- driven, customized intervention can improve quality of care and patient experience without an increase in total cost of care, while simultaneously transitioning practices to a population based payment model
No Statistically Significant Change
Transition from Fee for Service to Population Based
Cost of Care
Reduction of Hospital Admissions
Reduced ED Utilization
Quality of Care
Improved CAHPS Scores
Increased Deployment of Patient/Family Advisory Committees
Experience of Care

4. CPC Functions Risk Stratified Care Management
Iterative
Subjective Adaptations
Optimize Intervention Populations
Patient/Family Advisory Councils
Engaged/Empowered
Working Beyond “Satisfaction”
“Practice Ambassadors” To Your Community

5. CPC Functions Transitions of Care Teams (AR)
Engage Community Partners
Collaboration Culture (CO)
Best Practices Sharing
Team Based Care
Top of Licensure Protocols

6. Continuous Improvement Driven By Data
Comparative Data
Self, Peers, National
Patient Level Data
Ability to Drive Intervention
Data Transparency (OH)
Identify High Performers
Identify Similar Practices to Collaborate With

7. Enhanced Accountable Payment
Attribution
Prospective & Agreed
Physician Level Incentivization
Standardized Payer Reporting
Integrated, Aligned or Standardized
Payer Relationships (OK)
Moving Past Competitive Approach

8. https://innovation. cms

9. Evaluating the Impact of Change
A Quantified Approach
Cost=Quality=Experience= Satisfaction?
Per Capita Costs
An inverse relationship to desired outcomes
Quality of Care
A definitional battle of metrics
Patient Experience
Moving beyond “satisfaction”
Provider/Staff Satisfaction
An eye to sustainability

10. Comments / Questions