Table 1

Comprehensive Primary Care Services Expected by Medicare Fee-for-Service Beneficiaries for Innovation Center Enhanced Payment Eligibility

Primary Care FunctionsDescription
1. Risk-stratified care managementPatients with serious or multiple medical conditions need more support to ensure they are getting the medical care and/or medications they need. Participating primary care practices will deliver intensive care management for these patients with high needs. By engaging patients, primary care clinicians can create a plan of care that uniquely fits each patient’s individual circumstances and values
2. Ensure access to and continuity of careBecause health care needs and emergencies are not restricted to office operating hours, primary care practices must be accessible to patients 24/7 and be able to utilize patient data tools to give real-time, personal health care information to patients in need. Patients are best served when they receive their care from the same clinician or health team with whom they build a trusted relationship
3. Deliver planned care for chronic conditions and preventive carePrimary care practices will be able to proactively assess their patients to determine their needs and provide appropriate and timely preventive care. With disease registry capacity, practices can better track their chronically ill patients and provide the full range of timely and appropriate health services
4. Engage patients and caregiversPrimary care practices will have the ability to engage patients and their families in active participation in goal setting and decision making. Through a variety of policies and tools, patients can be full partners in truly patient-centered care
5. Coordinate care across the medical neighborhoodPrimary care is the first point of contact for many patients and takes the lead in coordinating care as the center of patients’ experiences with medical care. Under this initiative, primary care physicians and nurses will work together and with a patient’s other health care clinicians and the patient to make decisions as a team. Access to and meaningful use of electronic health records should be used to support these efforts