Table 1 Comprehensive Primary Care components and illustrative supporting milestones for 2013

1. Access and continuity

The primary care practice ensures that the patient has 24/7 access to speak with a practitioner or nurse who has access to the practice’s EHR system and ensures continuity between the patient and the PCP and care team.

Milestone: Practice defines the infrastructure (both technology and staffing) that supports 24/7 real-time access to practice’s EHR system.

2. Planned care for chronic conditions and preventive care

The primary care practice proactively assesses patients to determine care needs and provide appropriate and timely chronic and preventive care, including medication management and review.

Milestone: A care team member develops a personalized plan of care for high-risk patients and uses team-based approaches to meet patient needs efficiently.

3. Risk-stratified care management

The primary care practice delivers and manages care for patients with complex care needs (e.g., chronic illness and/or multiple comorbidities). The primary care practice empanels and risk stratifies its practice population and provides care management services to high-risk patients.

Milestone: Practice develops a risk stratification process and reports on the status of empanelment, data on the number of patients within each risk stratum, and information about care management processes, such as forming care teams or identifying and recruiting high-risk patients to receive care management services.

4. Patient and caregiver engagement

Primary care practice engages patients and their families in active participation in patient care and in guiding improvement in the system of care.

Milestones: Practice conducts an assessment of patient- and family-centered care and then engages in improvement activities informed by either conducting a practice-based survey or forming a patient and family advisory council.

5. Care coordination across the medical neighborhood

Primary care practice 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. Practice works closely with patients’ other health care providers, coordinating and managing care transitions, referrals, and information exchange.

Milestone: Practice identifies one area of care coordination (post-hospital discharge visit, emergency department follow-up phone call or visit, or referral tracking for specialist visits) for improvement and tracking.