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San Francisco Marin Medical Society Blog

5 Elements of Comprehensive Primary Care



Medicare has established five core primary care functions that payers will pledge to support under its new comprehensive primary care payment model. Physicians who apply and are chosen to participate in the demonstration would receive resources to perform these functions. Risk-stratified care management: Assessing all patients to identify and predict which ones need interventions, and developing care plans in consultation with patients. Access and continuity: Providing patients with 24-hour access to a designated health professional or care team. Planned care for chronic conditions and prevention: Offering proactive primary care through Medicare's annual wellness visit. Caregiver engagement: Establishing policies to ensure that patient preferences are determined and incorporated into treatment decisions. Coordinated care: Communicating key information during care transitions or referrals to other physicians. Source: Comprehensive primary care initiative, Center for Medicare & Medicaid Innovation, Centers for Medicare & Medicaid Services


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