Table 5 Example actionable findings from selected CPC practices about implementing risk-stratified care management and care coordination and how the findings informed CPC implementation

Intervention characteristics

Risk-stratified care management

Risk stratification and care management processes were seen as more complex and more time and resource intensive than anticipated. Practices faced challenges with documenting these activities and creating care plans in existing EHR systems.

(Complexity)

CMS modified materials for practices about different approaches for carrying out risk stratification.

The learning-support providers used this feedback to organize learning sessions and illustrative templates for practices about creating care plans with patients.

Care coordination

Practice members perceived care coordination activities (e.g., contacting patients after a hospital discharge) as beneficial because they ensured patient issues did not slip through the cracks and moved work from the clinician to a nurse care manager who carried out important activities, such as medication reconciliation.

(Relative advantage)

CMS and the learning-support providers provided practices with information about the value of teamwork to take advantage of the skills of nurse care managers, reduce clinician burden, and ensure important issues did not slip through the cracks.

Outer setting

Risk-stratified care management

Helping patients to self-manage chronic illness and make health-related lifestyle changes, particularly patients with limited social and economic resources, was identified by practice members as a common and time-consuming challenge to care management.

(Patient needs and resources)

The extent of time and resources required to meet patients’ social needs and help them with economic barriers (e.g., need for transportation for an appointment) received more attention from CMS. For example, CMS emphasized such factors as part of risk stratification scores (patients with greater socioeconomic needs might be higher risk) in the following year’s implementation guidelines.

Inner setting

Risk-stratified care management

Practices had EHR systems in place, but those systems often lacked the functionality to support documentation related to risk-stratified care management.

(Available resources)

CMS along with the learning-support providers created “affinity groups” to bring EHR vendor representatives and practices together to improve these EHR functions.

Characteristics of individuals

Risk-stratified care management

Practices that exhibited success in incorporating care management tended to have clinicians who believed in the value of care management and worked with patients and staff to incorporate the nurse care manager as part of the care team.

(Knowledge and beliefs about the intervention)

Some health system-owned practices modified their care management workflows based on their first-year experiences to try to embed a care manager at the practice (rather than having him or her located at the corporate office).

Implementation process

CPC overall

One-on-one, tailored practice coaching and problem-focused learning (e.g., peer-to-peer learning on overcoming specific challenges) for individual practices was a key contributor to practice-level improvement efforts.

(External change agents)

The learning-support providers increased opportunities for the practices to engage in peer-to-peer learning and (in certain cases) on-site practice coaching.