Reducing Acute Hospitalizations at High-Performing CPC+ Primary Care Practice Sites: Strategies, Activities, and Facilitators

Dana M. Petersen; Ann S. O’Malley; Laurie Felland; Victoria Peebles; Diane R. Rittenhouse; Rhea E. Powell; Eugene C. Rich; Rumin Sarwar; Asta Sorensen; Sheila Hoag; Mariel Finucane; Erin Lipman; Jonathan Gellar; Rachel M. Machta; Rosalind E. Keith

doi:10.1370/afm.2992

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Table 1.

Selected Characteristics of AHR High Performers at Baseline, 2016

AHR High Performer	Change in AHR, %^{^a}	Probability of Improving AHR, %^{^a}	Hospital/System Owned	No. of PCPs	No. of Beneficiaries^{^b}	Prior Transformation Experience^{^c}	County Location	State
1	−11	99	Yes	3-5	798	Yes	Urban	Kentucky
2	−9	99	Yes	≥6	2,674	Yes	Urban	Missouri
3	−6	91	Yes	≥6	2,991	Yes	Urban	Colorado
4	−6	91	Yes	≥6	2,206	Yes	Urban	Pennsylvania
5	−5	87	Yes	≥6	2,540	Yes	Rural	Montana
6	−6	86	Yes	≥6	889	Yes	Urban	Colorado
7	−6	83	No	3-5	831	Yes	Urban	New Jersey
8	−5	83	No	3-5	1,028	Yes	Suburban	Michigan
9	−5	83	No	3-5	929	Yes	Rural	Arkansas
10	−5	82	Yes	≥6	1,802	Yes	Urban	Oregon
11	−5	77	No	≥6	574	Yes	Urban	Ohio
12	−4	77	No	≥6	1,090	Yes	Urban	Rhode Island
13	−4	76	No	≥6	1,256	Yes	Urban	Ohio
14	−4	75	Yes	≥6	1,055	Yes	Rural	Colorado

AHR = acute hospitalization rate; PCP = primary care practitioner.
Sources: Mathematica’s analysis of data on the number, characteristics, and service use and spending of attributed Medicare beneficiaries based on Medicare Enrollment Database and claims data. Mathematica’s analysis of data on practice size and ownership from IQVIA’s SK&A Office-based Provider Database data; data on the number of attributed Medicare beneficiaries from Medicare Enrollment Database and claims data; data on participation in the Centers for Medicare & Medicaid Services’ (CMS’) Multipayer Advanced Primary Care Practice (MAPCP) and Comprehensive Primary Care Classic (CPC Classic); county data from the Area Resource File.
↵a Risk-adjusted and denoised percentage changes from 2016 to 2018 (Supplemental Appendix 1).
↵b Attributed Medicare fee-for-service beneficiaries in 2016.
↵c Includes patient-centered medical home (PCMH) recognition, MAPCP, or CPC Classic. A practice was considered to have PCMH recognition if ≥1 of its PCPs had recognition at some point in 2014-2017 by the Accreditation Association for Ambulatory Health Care, The Joint Commission, the National Committee for Quality Assurance, or the Utilization Review Accreditation Commission. A practice was considered to be an MAPCP participant if it participated in any year during 2011-2014, as determined by a file from CMS. Participants include practices that stayed enrolled in CPC Classic for at least the first 5 months.

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Table 2.

Comparison of AHR High Performers With All CPC+ Practices at Baseline, 2016

Characteristic	All CPC+ Practices (N = 2,888)	AHR High Performers (n = 14)
Practice site characteristics^{^a}
Practice size, %^{^b}
1-2 PCPs	34	0
3-5 PCPs	38	29
≥6 PCPs	28	71
Attributed Medicare fee-for-service beneficiaries in 2018, mean No.^{^b}	710	1,683
Prior transformation experience, %^{^c}	61	100
Hospital/system owned (vs independent), %	55	57
Enhanced CPC+ (Medicare and payer partner) payments per NPI in 2018, median (SE), $	42,964 (41,043)	47,559 (43,865)
Beneficiary characteristics^{^d}
Age group, y, %
≤64	16	17
65-74	47	46
75-84	26	26
≥85	12	11
Female, %	59	58
HCC score, mean (SE)^{^e}	1.08 (0.17)	1.14 (0.08)
Dually eligible for Medicare and Medicaid, %	15	16
Original reason for Medicare enrollment, %
Age	78	76
Disability	22	23
End-stage renal disease	1	1
Race/ethnicity, %
Black	7	8
White	86	87
Hispanic	1	1
None of above	6	4
Market characteristics
Household income in practice county, median (SE), $	54,208 (15,054)	53,164 (16,222)
Location, %
Rural	9	21
Suburban	15	7
Urban	76	71
Region, %
Northeast	29	21
Midwest	35	29
South	18	14
West	18	36
Number of acute care hospital beds per 1,000 population in practice county, %
1st quartile	26	21
2nd quartile	26	14
3rd quartile	26	59
4th quartile	22	14

AHR = acute hospitalization rate; CPC+ = Comprehensive Primary Care Plus; HCC = hierarchical condition category; NPI = national provider identifier; PCP = primary care practitioner.
Sources: See Table 1 footnotes.
Note: Percentages do not always add to 100 because of rounding.
↵a AHR high performers did not differ from CPC+ practices overall regarding Medicare Shared Savings Program status or CPC+ model track.
↵b A change in AHR in smaller practices could be due to chance from small sample sizes, rather than real change. Very small practices therefore tended not to be identified as AHR high performers because the Bayesian model could not achieve a high level of confidence of a real change based on a small number of attributed Medicare fee-for-service beneficiaries.
↵c See Table 1 footnotes for definition.
↵d Based on Medicare fee-for-service beneficiaries attributed to practices in 2016.
↵e Based on diagnoses in 2015. Score is normalized to a value of 1. Patients more healthy than average will have a score less than 1; those less healthy than average will have a score greater than 1.

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Table 3.

Prevalence and Perceived Level of Contribution of Activities (Within Strategies) to Reduce Acute Hospitalizations Within and Across AHR High Performers

Activities (Within Strategies)	Perceived Level of Contribution,^{^a} by AHR High Performer
Activities (Within Strategies)	1	2	3	5	4	6	7	8	9	10	11	12	13	14
Improve access to primary care
Same-day visits
Direct access by telephone
Urgent care sites (system run)
Expand care management
Follow-up after hospitalization/ED visit
Long-term care management
Specialized programs
Increase comprehensiveness of care
Broader services at practice
Broader and deeper care provided by PCP

AHR = acute hospitalization rate; ED = emergency department; PCP = primary care practitioner.
↵a = 0, not identified by respondents as a noteworthy factor for reducing their AHR; =1, perceived as a minor contributing factor to reduced AHR; = 2, perceived as a moderate contributing factor to reduced AHR; = 3, perceived as a major contributing factor to reduced AHR.

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Table 4.

Hypothesized Pathways and Illustrative Quotes for Activities (Within Strategies) to Reduce Acute Hospitalizations at AHR High Performers

Activities (Within Strategies) and Hypothesized Pathways	Illustrative Quotes
Improve access to primary care
Same-day visits: Increasing same-day appointment slots allows more patients to see a clinician at the practice quickly for urgent needs or concerns, and can help avoid primary care–treatable ED visits. Same-day visits also decrease the chance that an ED visit might result in admission, and help address clinical issues before they become more severe.	“More frequent and appropriate use of the acute [primary] care system prevents hospitalizations, and that’s what we are doing with same-day availability. Get ‘em in and get them assessed before they seek ED care or put off care that could result in an acute admission.” – Care manager “Just having that access and the spots on our providers’ schedules for acute visits helps. Before patients said it was easier to go to the emergency room. Now, they’re able to get in right away to see somebody.” – Care manager
Direct access by telephone: Sharing direct telephone numbers to care managers and encouraging patients to call (and having patients know that someone who knows them will answer or respond quickly) can increase patients’ likelihood of calling the practice when they have a question or concern rather than turning to the ED. It also promotes earlier intervention to prevent exacerbations that might lead to an ED visit or hospital stay.	“We had started an after-hours on-call number we gave to the patients, put on our cards also, that gave them access to a nurse care manager after hours and on the weekends. And I believe with us being able to triage those patients and take care of their needs, that has reduced them going to the ER and the hospital for hospital stays.” – Registered nurse “We have strict standards in terms of coverage telephone after hours. We try to make sure that they [patients] are told to come to the office the next day instead of the emergency room, if appropriate.” – Registered nurse
Urgent care sites (system run): Establishing urgent care access with EHR linkages to the primary care practices provides as alternative to the ED for patients to receive treatment for an acute episode when the practice is closed and may prevent ED visits and lower the chance of hospital admission.	“… in our community, we didn’t have an urgent care center before, so patients used our emergency room at our local hospital instead. By adding the urgent care here, we can keep people out of the hospital whether it’s in the emergency department or being admitted.” – PCP “[These same-day care centers are] very different from other urgent cares in the community. These are our own people and it’s really very much a primary care–driven approach… when you had a patient that went to these centers, it was really more like they saw one of your partners in the office. The centers are open until 8 at night and for 4 hours on Saturday and Sunday. I think that was a pretty major driver [of reduced AHR].” – System lead
Expand care management
Follow-up after hospitalization/ED visit: Connecting with patients immediately after discharge from the hospital or ED provides patients with information, support, and linkages to care that can prevent future hospitalizations. For example, practices could identify and address issues with medications, transportation, and DME services needed after discharge and schedule timely follow-up with primary care. Transitions of care are also an opportunity to funnel patients to longitudinal care management services.	“There are so many different things that bring a person back to the hospital… couldn’t afford the copay, didn’t have a ride to the pharmacy, and so on. We wanted to keep [our follow-up calls] very open-ended, and a robot can’t do that. I’m all for IT, but you really need a human who is listening to what you’re going through and so that was the core of our transitional care; we really wanted that personal touch.” – Program manager “An integrated Transition of Care Management program was the biggest lever on the AHR, not just a person. The care manager was vital, but she would not have been successful without the other things that she fit into and benefited from. So not just a person, it’s a process and a program.” – System lead
Long-term care management: Identifying and engaging patients with complex or comorbid conditions in relationship-based longitudinal care management can prevent or lessen the severity of exacerbations that might otherwise require hospitalization.	“[It’s been] important to have a team that tackled high-risk patients and hospitalizations together as a team. Divvied up the work, made sure they took care of all the details.” – PCP
Specialized programs: Offering clinical programs designed for subgroups of patients at high risk for hospitalization can allow practices to identify emerging issues early and focus services where they may have the largest impact on hospitalization.	“We saw our COPD admission rate and readmission rate drop dramatically from [the specialized albuterol program]. We identified patients that may be experiencing COPD exacerbations by tracking their albuterol refill rate. Their refill rate triggered us to reach to those patients.” – PCP “Like our A_1c [values]—we watch our diabetic patients. We watch our diabetic patients a lot closer than we used to. I think it helps us catch things early. It helps them realize, ‘Oh my gosh, my A_1c is super high,’ and it brings it to their attention to improve on those so that they don’t end up in the hospital.” – Care manager
Increase comprehensiveness of care
Broader services at practice: Viewing the needs of the whole person rather than just isolated problems might lead to fewer hospitalizations. Expanding the ability to provide services such as behavioral health, pharmacy, and social service support can prevent exacerbations of chronic conditions that might lead to hospitalization and reduce the likelihood of presentation for new conditions requiring hospitalization.	“I think that it [CPC+] just brought to the forefront that, you know, trying to take care of the whole patient with the education, working with the team on getting the full picture of what this patient needs, and keeping the patient involved in what they need to do to stay out of the hospital. I think that just seeing all of that together and not just piecing things together and just taking care of 1 problem when they come in, but doing the whole person.” – Care manager “We’ve got this team of physicians, of pharmacists, of care coordination, and also of integrated behavioral health. All these could potentially work together to make certain a person needs to go to the hospital, vs being treated at the practice, and we can make those decisions as a team.” – PCP
Broader and deeper care provided by PCP: Transitioning tasks to others frees up PCPs so they can spend more time on care of patients with complex needs—and thus better understand patients’ circumstances and conditions, ensure appropriate diagnosis and treatment plans, and build trust.	“I felt freed up to do those things that I really wanted to do, as a doctor, to actually talk to my patients and have them take care of their health. Shifting the nonprovider work to nonproviders allowed us that extra time to do these provider things we really wanted to do, that made us feel good about our work.” – PCP “We have longitudinal relationships with patients, which gives us more time with patients to learn about social determinants that affect their health, to communicate to patients how to better care for themselves, and the ability to notice changes to the patients’ health over time and intervene early.” – PCP

A_1c = glycated hemoglobin; AHR = acute hospitalization rate; COPD = chronic obstructive pulmonary disease; CPC+ = Comprehensive Primary Care Plus; DME = durable medical equipment; ED = emergency department; EHR = electronic health record; IT = information technology; PCP = primary care practitioner.

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Table 5.

Facilitators of AHR High Performers’ Efforts to Prevent Acute Hospitalizations

Facilitator	Mechanism^{^a}	Illustrative Quote
Experience with and investment in practice transformation	Provided practices necessary payment structure, incentives, resources, and capabilities to track AHR Offered learning supports that helped practices use data and adopt new workflows	“CPC+ was the first time we were responsible for total cost of care… that we, as a practice, were financially connected to the hospitalization rate. We weren’t measuring that at the practice level [before CPC+]. Once we had a financial connection and mechanism to track that, we completely changed our workflows.” – PCP
Use of data from CPC+, other payers, health systems, and electronic health record enhancements	Enabled practices to monitor high-risk patients, intervene early in their care, and link them to helpful resources Improved PCPs’ ability to make point-of-care decisions	“All of a sudden, we were given lists that say, ‘These are your 10% of patients who are hospitalized the most or have the most ED follow-up, the most chronic disease.’ By identifying these patients, we were able to link them to our new ancillary services [within the primary care practice site] and really tackle the reasons that they’re not doing well.” – PCP
Implementation or enhancement of primary care teams through team-based care models	Allowed staff to work at the top of their license and cover for each other to prevent gaps in care Strengthened patients’ trust in care team members in addition to PCPs	“I think how cohesively the care team works together makes a big impact. At many of our [non–AHR high-performer] sites, often the care team doesn’t make a move without getting the provider’s permission first. The fact that [we’ll] just dive into what the patient needs right then, and then loop in the provider later is unique.” – PCP
Organizational support for and staff interest in innovation	Gave staff permission to try new approaches and take risks Helped staff implement and hone new workflows and processes Fostered a focus on using data to identify issues and implementing quality improvement projects Enabled system-owned AHR high performers to undertake investments that would be too expensive to make on their own	“We are very open [to our staff] identify[ing] potential problems. Small acts of change, or small plan-do-study cycle–type projects we do at an ongoing, never-ending basis. [This practice has] been very, very supportive of small tests of change consistently, [whether that is] workflow changes [or] IT changes. And because we’re making microchanges consistently, they tend to stick because they’re not huge changes to the workflow redesign.” – Pharmacist

AHR = acute hospitalization rate; CPC+ = Comprehensive Primary Care Plus; ED = emergency department; IT = information technology; PCP = primary care practitioner.
↵a Mechanism by which the facilitator supported care delivery activities within the 3 overarching strategies.