Comprehensive Primary Care, Plus More

April 25, 2017   |  Tags: Blog   |  Tags: CPCI , CMS
Bhavaya Sachdeva, MPH

Sixty-four Oregon practices completed all four years of the Comprehensive Primary Care initiative at the close of 2016 after achieving significant improvements in quality and reducing utilization of care. In response, the Center for Medicare and Medicaid Innovation (CMMI) of the Centers for Medicare and Medicaid Services (CMS) launched an advanced model of this initiative, Comprehensive Primary Care Plus (CPC+), in January 2017 with 156 enrolled Oregon practices supported by 15 local payers. CPC+ is the largest national primary care payment and clinical practice redesign initiative in U.S. history. Nationally, the model includes 54 payers that support 2,891 primary care practices, consisting of 13,090 clinicians, and serving more than 1.76 million Medicare, millions of Medicaid, and a large number of commercially-insured beneficiaries across 14 regions. CMS will reopen solicitation for practices and payers beginning in January 2018, allowing practices in up to 10 new regions to apply, accepting a maximum of 5,500 practices across rounds one and two. Payers in new regions as well as new payers in existing regions will be welcome to apply.

The regional learning network in Oregon is led by Dr. David Dorr from Care Management Plus (CMP) and Dr. Ronald Stock from the Oregon Rural Practice-based Research Network (ORPRN). CMP and ORPRN provided technical assistance and targeted facilitation to the CPC Classic practices over the past four years. Practices were successful in adding care management staff, pharmacists, behavioral health programs and providers, and patient and family advisory councils. Oregon practices also reduced hospitalization rates by 9.2% and 30-day unplanned readmissions rates by 6.7% amongst Medicare beneficiaries from one year prior to the initiative through March 2016. Additionally, all practices were successful in achieving quality benchmarks in 2015 and qualified for regional shared savings.

CPC+ practices, organized into Tracks 1 and 2, will continue to receive national learning content, as well as technical assistance and tailored facilitation from the regional learning network team. The CPC+ aims focus around the five key Comprehensive Primary Care functions, which are: access and continuity, care management, comprehensiveness and coordination, patient and caregiver engagement, and planned care and population health. CPC+ practices had an opportunity to engage in conversations around these functions at the first CPC+ Oregon In-Person Learning Session held on April 11th at The Armory in Portland, OR. The session was attended by 335 attendees representing 130 CPC+ practices. Foundations were laid for future work around empanelment and access, risk stratification, implementation of patient and family advisory councils, as well as collaborations between practices and payers.

CMP and ORPRN will continue to build upon our relationships with Oregon practices, and to utilize our combined expertise in practice facilitation, health information technology support, risk stratification, and practice transformation to continue to support the practices in CPC+. Oregon primary care practices have been at the forefront of healthcare quality change and implementation of value-based payment methodologies, and will continue to light the path forward.

Learn more about the initiative and see which practices are participating here:

Learn more about the Care Management Plus (CMP) team at OHSU:


*The views expressed in this post are those of the author alone and do not represent those of the Centers for Medicare & Medicaid Services or the U.S. Department of Health and Human Services.


Bhavaya Sachdeva, MPH, holds a Master of Public Health degree from OHSU and a Bachelor's degree in Chemistry and Business Administration from the University of Oregon. She is the Program Manager for the Care Management Plus team, providing leadership and oversight to all grants and projects, and serves as a Project Manager for the Oregon CPC+ regional learning network.

Her previous experiences include managing a clinical and financial data team, as well as managing several grants related to using data for quality improvement and health delivery, preparing residents to care for the mental health needs of patients, and improving documentation for depression in the EHR. Bhavaya also has past clinical experience in an Urgent Care setting, as well as with quality improvement and Medical Home transition projects at a community health center.