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Through a unique public-private partnership with 54 aligned payers in 14 regions (PDF), the CPC+ payment redesign gives practices the additional financial resources and flexibility they need to make investments that will improve quality of care and reduce the number of unnecessary services their patients receive. 


CPC+ seeks to improve the quality of care patients receive, improve patients’ health, and spend health care dollars more wisely. Practices in both tracks will make changes in the way they deliver care, centered on key Comprehensive Primary Care Functions: (1) Access and Continuity; (2) Care Management; (3) Comprehensiveness and Coordination; (4) Patient and Caregiver Engagement; and (5) Planned Care and Population Health.


CPC+ was developed by the Center for Medicare and Medicaid Innovation to test innovative payment and service delivery models – including primary care payment and care delivery reform – to reduce CMS program expenditures and improve quality for Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) beneficiaries.


How Can CHADIS Help?


Comprehensive Primary Care Functions


FUNCTION 1: Access and Continuity - Among other factors, CPC+ seeks to increase the likelihood that the patient will get the right care at the right time to provide the necessary treatment before a condition becomes urgent and costly.


CHADIS provides this through an automated delivery system of reminders for age-appropriate developmental screening appointments.

FUNCTION 2: Care Management - Care management for high-risk, high-need patients is a hallmark of comprehensive primary care and CHADIS provides a way to identify high-risk patients through the use of over 400 screening, diagnostic and data collection tools and questionnaires. Once a condition has been identified CHADIS provides clinicians with “moment of care” decision support, including a unique CHADIS feature, called a "
Patient Specific Template" (PST).


For instance, CHADIS proactively manages chronic and preventive care using evidence-based protocols to guide treatment of asthma through the use of the Asthma Care Patient Specific Template.  Clinicians gather on-line, pre-visit asthma information from the patient, receive tailored clinical ‘Next Steps’ to easily follow during the visit, receive "problem solving counseling" suggestions to address adherence, efficiently create an individualized Asthma Treatment (Asthma Action) Plan with the patient/family, receive tailored resources for the patient/family, and have access to clinician education all while earning Part 4 MOC credits. All of the data, information, and plans are then documented within your EHR.


Tools available for management of asthma through CHADIS:  Pediatric Asthma Control & Communication Instrument (PACCI), CHADIS Environmental Triggers & Smoke Exposure Questionnaire, CHADIS Asthma Parent Priorities, CHADIS Asthma Parent Perception Rating, CHADIS Asthma Medications (Adherence), CHADIS Asthma Medical History, and Asthma Control Test 4-11 & 12+ versions.


FUNCTION 3: Comprehensiveness and Coordination - Comprehensiveness in the primary care setting refers to the aim of practices meeting the majority of its patient population’s medical, behavioral, and health-related social needs in pursuit of each patient’s health goals. Practices participating in CPC+ will act as the hub of care for their patients, playing a central role in helping patients and caregivers navigate and coordinate care.


CHADIS provides a comprehensive array of screening and diagnostic tools for developmental checks, general health, and mental and behavioral health. In addition, CHADIS offers decision support and visual aids to assist in patient/family shared decision making. Clinicians are able to securely share the data with other practitioners and also receive input from teachers and other specialists.


For example, CHADIS offers the ADHD Patient Specific Template (PST), the ADHD PST gathers pre-visit ADHD information from parents AND teachers without any clinician effort. 


The pre-visit ADHD-related questionnaires cover all essential questions for an ADHD check-up visit. This includes parent and teacher Vanderbilts, screening for DSM disorders, and more. School data is essential to optimizing ADHD care and medications. Teachers can be “invited” by parents or staff to complete Vanderbilts via CHADIS with FERPA compliant online parent consent forms.  


Each PST provides a tailored graphic to be shown to families, illustrating the patient’s ADHD challenges over time, facilitating discussion. The PST suggests tailored, research-supported, goals for clinicians to review with parents. Parents are sent specific suggestions for how to accomplish the chosen goals. Selected goals are also listed in subsequent PSTs, so clinicians are reminded to follow-up on progress. The 504 plan and IEP letters can be automatically generated as well as post-visit messages tailored to the parent’s goals and challenges. Printable handouts and local resources are all accessible to the parent online in the CHADIS MemoryBook Care Portal.  


Relevant questionnaire data pre-populates the PST and any further PST clinician actions are automatically documented. In addition, MOC Part 4 credits can be earned without chart review!


FUNCTION 4: Patient and Caregiver Engagement - Optimal care and health outcomes require patient and caregiver engagement in the management of their own care and in the design and improvement of care delivery.  


The hallmark of CHADIS's Patient Specific Templates (PSTs) is patient engagement. PSTs provide advanced decision support that incorporates patient submitted pre-visit data to reduce documentation burden, highlights data which appears within evidence-based guidelines, reports data & clinician selections for PCMH, MACRA , QI, etc., and creates personalized patient education and engagement.


FUNCTION 5: Planned Care and Population Health - Using team-based care, practices will proactively offer timely and appropriate preventive care and consistent evidence-based management of chronic conditions. Practices will improve population health through the use of evidence-based protocols in team-based care and identification of care gaps at the population level. 


Through CHADIS's automated delivery systems of reminders for age-appropriate developmental screening appointments and Patient Specific Templates, clinical teams are able to provide evidence-based preventative care and management of chronic conditions like ADHD and asthma with ease.


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