Making Primary Care, Primary

Making Primary Care, Primary

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Communication is at the Heart of CMS’s MCP Program Success

This may be the era of Primary Care in healthcare. The weight of primary care and general practitioner physicians in the care continuum has made the Centers for Medicare & Medicaid (CMS) take notice and enhance their efficacy by initiating and profoundly investing in the MCP model for both prevention and post-acute care coordination. Within the framework developed by CMS’ Centers for Medicare & Medicaid Innovation (CMMI), effective communication is a crucial element to ensuring the success of the MCP model.

Rising costs coupled with a 17.3% aging population with intricate needs (as of 2022), and a shifting emphasis towards value-based care have considerably changed the face of primary care. The rationale behind this is that robust primary care serves as the foundation for overall population health. CMMI maintains that ensuring equitable care is vital for delivering high-quality healthcare to Medicare and Medicaid beneficiaries, thus making it essential for the success of MCP.

A Primary Care Provider can act as a liaison among different clinicians and specialists, potentially slowing the onset or progression of a chronic or fatal disease. Emerging technologies hold immense potential to enhance care coordination for patient centricity by facilitating seamless information, exchange and shared decision-making among various healthcare stakeholders. But to ensure patients receive a holistic and seamless care experience leading to better health outcomes the importance of effective and real-time communication needs to be considered the backbone of the shift.

Those participating in CMS’ new Making Care Primary (MCP) model will be interested to note how the agency is encouraging and facilitating their participation in improved communication with other members of the patient’s care team and across the continuum.

The role of effective communication that includes Primary Care Physicians along with allied care, family, and oftentimes the patient themselves is especially crucial for the aging demographic, necessitating nuanced and coordinated care, which is attainable with effective communication.

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However, caring for older adults comes with unique communication challenges.  Managing multiple caregivers, each with their own communication tools and preferences, adds a layer of complexity. Particularly when those tools and methods need to adhere to privacy & security requirements such as HIPAA.

Additionally, when communicating with older patients directly Cognitive decline can hinder comprehension and informed decision-making without the support of others such as family.

When the providers and the care team overcome these challenges everyone benefit and all aims of the MCP and other accountable care models are realized:

  • Earlier Detection & Proactive care: Early detection and management of chronic conditions like diabetes, heart disease, and dementia is realized;
  • Care coordination: PCPs, home care, allied care, social services, and coordinating specialists are all working in unison;
  • Personalized Care Plans: Tailored to individual needs and with input from all care giving team members through improved communication, personalized care plans are more robust taking into account physical, cognitive, and social factors;
  • Build Trust: Long-term relationships with PCPs are strengthened with greater trust and adherence;  and,
  • Reduce Burnout.  Improved communication reduces burnout for the care team and creates a greater level of job satisfaction.

Those engaged in the CMMI’s MCP initiative enjoy a spectrum of advantages: 

  • Financial incentives: Earn bonus payments by attaining program goals, particularly in

Communication and patient engagement

  • Technical assistance: Benefit from CMS support in adopting cutting-edge practices and inventive communication solutions.
  • Data and analytics: Gain access to comprehensive data for progress monitoring and pinpointing areas ripe for enhancement.
  • Collaboration and learning: Engage in a dynamic learning community alongside other participants, fostering the exchange of best practices and celebrating successes.
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CMS has affirmed that strengthening the ‘primary care stage’ of the care continuum is essential for achieving excellence in its core purpose: improving patient outcomes, lowering costs, and reducing disparities. Also, patient-centric, effective, and real-time communication is paramount, as without it, the desired results may not be realized.

To take advantage of these opportunities, CMS is offering the following supports to those wishing to participate in the MCP initiative:

  • Educational webinars and workshops, focusing on the benefits of improved communication and practical implementation strategies.
  • Financial support, by offering grants and other resources to help practices invest in communication technologies [secure, multilingual messaging platforms that can bridge gaps] and training.
  • Recognition and visibility through highlighting success stories and showcasing innovative practices.
  • Providing additional resources & data so they can better coordinate care with specialists
  • Expanding healthcare access and establishing lasting change in underserved communities through fostering collaborations with state Medicaid agencies, social service providers, Federally Qualified Health Centers (FQHCs), and specialized care providers.
  • Enhances the management of care, community relationships, and the integration of care by offering capacity-building resources to those entering the realm of value-based care.
  • Assists primary care practices in providing enhanced support to patients in managing their health, particularly those with complex and chronic health conditions.
  •  Empower primary care providers to deliver a more extensive array of healthcare services tailored to the requirements of their patients. For instance, practices can provide 24/7 access to clinicians and assistance for health-related social needs.
  •  Offers improved compensation for primary care services to encourage greater investment in the field.
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Primary Care Providers should be looking at CMS’ MCP program with great interest.  It offers significant opportunities to progress primary care to the forefront of care coordination efforts particularly amongst senior and post-acute care.  However doing so requires a concerted focus on communication with all participants across the care continuum.  CMS and CMMI are offering significant support in terms of remuneration, education, and technology to facilitate participation.  PCPs should consider participating for the benefits of patients, their staff, and themselves.

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