Care Transformation

One of the priorities for the Maryland Health Care Commission (MHCC) is to support advanced primary care and practice transformation to shift the focus from quantity of care delivered to improved health outcomes and coordinated care delivery.  Advanced primary care activities and demonstrations are aimed at implementing a new fundamental strategy focused on patient needs, where primary care is the foundation for maximizing value in health care delivery through better health outcomes and lower costs.

Care Management Readiness Assessment 

The MHCC developed a free interactive guide for ambulatory practices - the Care Management Capabilities and Readiness Assessment Guide (CMRA).  The CMRA includes a practice self-assessment to determine care management preparedness, help practices design a care management program, define a care manager’s role in a practice, and identify leading care manager responsibilities.  The CMRA also includes about 65 care management resources to help practices implement care management and enhance an existing care management program. Click "Enable Content" to maximize automation. 

Patient and Family Advisory Council Guide for Ambulatory Practices

The Patient and Family Advisory Council Guide for Ambulatory Practices (Guide) provides Maryland ambulatory practices (practices) with information and resources to help create, integrate, and expand a Patient and Family Advisory Council (PFAC).  PFACs are a key component for practice quality improvement and an ongoing mechanism to support meaningful partnerships among patient and family advisors, staff, clinicians, and organizational leaders.  

For a copy of the Guide, click here.

Engaging Patient and Family Advisory Councils During COVID-19 Lunch & Learn Webinar, November 2020 RecordingPresentation

Addendum to the Patient and Family Advisory Council (PFAC) Guide for Ambulatory Practices

In the Fall of 2020, MHCC convened PFAC focus groups to discuss changes to PFACs implemented in response to the COVID-19 public health emergency.  Focus groups included representatives from 39 Maryland practices.  The Addendum to the PFAC Guide for Ambulatory Practices provides actionable steps to support patient and family engagement when there are limitations on convening in-person meetings. Click here for the addendum.

Innovative Care Delivery Symposium 

The MHCC convened the first of a three-part virtual symposium series in collaboration with the Health Services Cost Review Commission and MedChi, The Maryland State Medical Society.  Presentations focused on the evolution of quality measurement and value-based care delivery models; approaches and strategies for team-based care across the medical neighborhood; and multi-disciplinary team approaches to managing high-risk and high-utilizer patients.  Links to the session are below.

Session 1:  Innovative Models for Managing Patient Populations (November 2021) 

Click here for a copy of the slides.  Click here to listen to the recording.

Session 2:  Innovative Team-Based Care (December 2021) 

Click here for a copy of the slides.  Click here to listen to the recording. 

Session 3:  Innovative Value-Based Payment Models (January 2022)

Click here for a copy of the slides.  Click here to listen to the recording. 

Health Equity Roundtable 

The MHCC convened a Health Equity Practice Roundtable (HE Roundtable) with representatives from advanced care delivery practices.  The purpose of the HE Roundtable is to identify challenges and opportunities for practices seeking to address key health equity concerns in their communities.  The MHCC aims to advance health equity in ambulatory practices in Maryland through the development of health equity practice resources informed by HE Roundtable feedback.

Roundtable Meeting Materials:

July 13, 2022:  Recording, Meeting Summary, and Discussion Guide

June 1, 2022:  Recording, Meeting SummaryDiscussion Guide, and Presentation 

May 4, 2022:  Recording, and Meeting Summary

March 30, 2022:  Recording, Meeting Summary, and Briefing Document

Patient Reported Outcomes (PRO) Measures Roundtable 

The PRO Measures Roundtable includes advanced care delivery representatives along with select payers, consumers, and practices.  The aim of the roundtable is to identify challenges and opportunities for practices seeking to implement PRO measures in care delivery.  The roundtable discussion will inform the development of PRO measure resources for practices, such as information briefs or learning symposiums.

Roundtable Meeting Materials:

April 20, 2022:  Recording, Meeting Summary, and Presentation

Maryland Primary Care Program

(This was previously named the "Maryland Comprehensive Primary Care Model) 


Maryland, under agreement with the Centers for Medicare & Medicaid Services (CMS), launched the All-Payor Model in 2014 to transform the health care delivery system.  The All-Payer Model is changing the way Maryland hospitals provide care, shifting from a financing system based on volume of services to a system of hospital-specific global revenues and value-based incentives.

In 2018, CMS approved the Total Cost of Care (TCOC) Model that expands on the All-Payer Model. The TCOC Model priorities include enabling access to quality health care, addressing the health and wellness needs of the senior population, reducing unnecessary emergency department and hospital utilization, fighting the opioid epidemic, and improving population health.  The Maryland Primary Care Program (MDPCP) is a key initiative under the TCOC Model.  The MDPCP integrates care management into primary care and speciality provider practices to advance primary care throughout the State. 

More information on the MDPCP may be found here.

The MHCC convenes and staffs the MDPCP Advisory Council.  The Secretary of the Maryland Department of Health requested in January 2019 that an Advisory Council (Council) be established.  The Council makes recommendations for inclusion in the State's annual report to CMS on MDPCP; considers operational improvements to the MDPCP, including suggested modifications to the care delivery requirements; gathers data from MDPCP participants and beneficiaries to support issue research; and requests other Maryland Department of Health agencies to examine specific issues.  A list of Council members is available here.

MDPCP Advisory Council Subgroup Recommendations - Innovative Practice Alternatives and Practice Reporting (April 2021)

The MHCC convened two subgroups of the MDPCP Advisory Council:  Innovative Practice Alternatives and Practice Reporting.  Subgroup discussions explored MDPCP evaluation metrics, reducing practice reporting requirements, and financing opportunities that reward value and quality. The recommendations are intended to inform MDPCP enhancement considerations.

MDPCP Advisory Council Meeting Materials:

September 13, 2022:  RecordingMeeting Summary,  MHCC PresentationFreedman HealthCare Presentation, PMO Presentation, and HSCRC Presentation

January 11, 2022:  Recording, Meeting Summary, and PMO Presentation

October 26, 2021:  Recording, Meeting Summary, PMO Presentation, and Health Equity Presentation 

August 10, 2021: Recording, Meeting Summary, Presentation, and MACRA Timeline

May 4, 2021:  Recording, Meeting Summary, and Presentation

December 15, 2020: Recording, Meeting Summary, Track 3 Policy Summary, and Presentation

December 8, 2020:  Recording, Meeting Summary, and Presentation

December 1, 2020: RecordingMeeting Summary, Track 3 Performance Adjustment, and Presentation

November 17, 2020:  Recording, Meeting Summary, PMO Policy Outline,  and Presentation

November 10, 2020:  Recording, Meeting Summary, and Presentation

October 27, 2020:  Recording, Meeting Summary, and Presentation

October 20, 2020:  Recording; Meeting Summary, and Presentation

October 6, 2020:  Recording, Meeting Summary, and Draft Track 3 Requirements Table

September 29, 2020:  Recording, Meeting Summary, and Draft Track 3 Requirements Table

September 22, 2020:  Recording, Meeting Summary, and Draft Track 3 Requirements Table

September 15, 2020:  Recording, Meeting Summary, and Draft Track 3 Requirements Table

September 1, 2020:  Recording, Meeting Summary, and Draft Track 3 Requirements Table

August 25, 2020:  Recording, Meeting Summary, and Draft Track 3 Requirements Table

August 18, 2020:  Recording, Meeting Summary, and Draft Track 3 Requirements Table

March 27, 2020:  Notice to Public of Emergency Meeting and Advisory Council Action

February 13, 2020:  Presentations

December 4, 2019:  Recording and Presentation

October 22, 2019:  Recording

MDPCP Advisory Council Track 3 Subcommittee Meeting Materials:

August 4, 2020 Recording and Meeting Summary

July 28, 2020 Recording and Meeting Summary

July 21, 2020 Recording and Meeting Summary

July 14, 2020 Recording and Meeting Summary

Federally Qualified Health Centers (FQHCs) Lunch & Learn Webinar

The MHCC hosted an Improving Quality and Preparing for the Maryland Primary Care Program Lunch and Learn Webinar on December 9, 2019. The webinar shared information on quality improvement activities to enhance care quality in FQHCs and opportunities available in the Maryland Primary Care Program. The recorded webinar is available here and the slides may be found here.

Podiatry Merit-based Incentive Payment System (MIPS) Lunch & Learn Webinar (April 2020) 

The MHCC hosted a webinar for podiatrists with a presentation from a practicing podiatrist who is also a MIPS expert. The webinar provided information about strategies to enhance practice's performance and reimbursement in MIPS.  Click here for a copy of the slides; click here to listen to the webinar on-demand.

Podiatry Telehealth Lunch & Learn Webinar (June 2020) 

Maryland podiatrists and MHCC staff provided an overview on adopting telehealth in a podiatric practice. The webinar included information about best practices, lessons learned, and telehealth adoption resources. Click here for a copy of the slides; click here to listen to the webinar on-demand.

Podiatry Cybersecurity Lunch & Learn Webinar (March 2021)

Two Qualified Maryland Cybersecurity Sellers, a Maryland podiatrist, and MHCC staff provided information on key strategies for enhancing cybersecurity in podiatric practices.  Click here for a copy of the slides; click here to listen to the webinar on-demand.

Advancing Practice Transformation Lunch & Learn Webinar (April 2021) 

A CMS Quality Improvement Organization subcontractor and a Medicare quality reporting physician consultant provided an overview of the 2021 Quality Payment Program updates. The presentation also included tips and resources for succeeding in MIPS.  Click here for a copy of the slides; click here to listen to the webinar on-demand.

Podiatry MIPS Webinar (October 2021)

The MHCC convened a podiatry webinar featuring a national podiatric MIPS subject matter expert.  The webinar focused on optimizing performance in MIPS.  Information provided included tips on measure selection to improve practice performance.  Cllick here for a copy of the slides.  Click here to listen to the webinar.

Podiatry Remote Patient Monitoring Webinar (March 2022)

The MHCC hosted a webinar on implementing remote patient monitoring (RPM) in a podiatric practice.  The webinar focused on best practices for selecting RPM technologies and navigating the payer reimbursement process.  Click here for a copy of the slides.  Click here to listen to the webinar. 

Assessing and Vetting Community Resources Lunch & Learn Webinar (May 2022)

The MHCC convened a webinar featuring clinicians from Carroll Hospital and Adventist HealthCare.  Presentations focused on identifying statewide community resources, determining capacity of community resources, and leveraging and prioritizing partnerships with community resources.  Click here for a copy of the slides; click here to listen to the webinar on-demand.

Practice Transformation Network 

The CMS developed a Transforming Clinical Practice Initiative (TCPI) to assist providers in achieving practice transformation to align with the innovative strategies of the Affordable Care Act. CMS awarded 29 organizations a Practice Transformation Network (PTN) Cooperative Agreement to collaboratively lead practices through the transformation process.  The MHCC, in partnership with MedChi, The State Medical Society, and the Department of Family and Community Medicine at the University of Maryland School of Medicine, worked with the New Jersey Innovation Institute, a CMS PTN awardee, as a sub-contractor for implementing practice transformation activities in Maryland

The PTN supports clinical practices throughout the transformation process from fee-for-service to value-based reimbursement.  The national goal for TCPI is to transform 140,000 clinicians and save $1.4 billion in health care costs.  The goals are achieved through alternative payment methods, value-based incentives, patient-centered care, and improved health care outcomes.  The PTN helps transform practices by offering the following assistance:

  • Customized coaching;
  • Leverage meaningful use;
  • Identify and incorporate patient centered medical home model concepts into practice workflows; 
  • Support for reporting measures for the physician quality reporting and interpreting the results;
  • Measure outcomes for value-based payments under MACRA;
  • Alternative payment preparedness;
  • Navigate reporting programs for CMS compliance under MACRA; and
  • Data analysis for quality workflow and revenue improvement.

The PTN focuses on the following metrics;




 Adult Smoking Reduction


 HbA1c Poor Control Cost Savings due to decrease cost of hospitalizations


 Controlling high BP for patients with hypertension aged 18-85


Reduction of Cardiac stress imaging for low risk patients


Inappropriate imaging for low back pain


Potentially Preventable ER Visits (PPV) – Primary Care Related and Non-Emergent


Advanced Care Plan


Third next available appointment (TNAA) - Total # practices with measure fully implemented


Increase Transitional Care Management (TCM)


Reduction in unplanned 30 day readmissions per 1,000

PTN Resources

Maryland PTN Final Report

PTN Activities

PQRS Flyer

PQRS List of Eligible Professionals


TCPI Change Package

TCPI PFE Compendium

MACRA Awareness and Support (MAS)

In April 2015, Congress passed the Medicare Access and Children's Health Insurance Program Reauthorization Act of 2015 (MACRA).  This legislation aims to significantly move the needle on health care delivery payment reform starting, with Medicare, with the aim of expanding to Medicaid and commercial markets. Practices in Maryland—especially small practices located in rural or underserved areas and/or not affiliated with a hospital—need technical and administrative support to transform practice workflows and optimize the use of health IT.  The MAS Program will assist stakeholders subject to MACRA, such as ambulatory practices and hospitals, in adjusting their current approach and practice management based upon MACRA's specifications.  

Last Updated: 1/10/2023