Advanced Primary Care

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.

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.

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, shirfting from a financing system based on volume of services to a system of hospital-specific global revenues and vlaue-based incentives.

Further health transformation in Maryland means transitioning to an All-Payor Model that limits the growth in total cost of care for Medicare beneficiaries in a second term that will begin on January 1, 2019.  In the "Progression Plan" document, Maryland outlines its proposal to accomplish the expanded system-wide goals and address the State's goal of including the Medicaid costs for Medicare beneficiaries who are also covered by Medicaid.

A key component of the Progression Plan is system-wide primary care transformation.  Primary care is essential for patients with chronic diseases that progress over time, to prevent them from having to seek care in higher acuity care settings.  However, many primary care settings lack the resources to meet the full range of needs of the growing number of patients with multiple chronic conditions.  Necessary resources include care management, care coordination, and connections to behavioral health and social services.  Maryland is developing the Maryland Primary Care Program (MDPCP) to integrate care management into primary care and specialty provider healthcare practices.

More information on the proposed Maryland Primary Care Program may be found here.

Transforming Clinical Practice Initiative

The Centers for Medicare and Medicaid Services (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, is working 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

PTN Activities

PQRS Flyer

PQRS List of Eligible Professionals


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.  

Maryland Multi-Payor Patient Centered Medical Home Program

The Maryland Multi-Payor Patient Centered Medical Home (PCMH) Program (MMPP) pilot was program testing the effectiveness of the PCMH model in 52 Maryland Primary Care practices.  The program began in April of 2011 and ended in June of 2016.  The MMPP was a catalyst for practice transformation in Maryland by providing financial support and individual practice coaching for participating practices.  The MHCC and IMPAQ, International, LLC conducted an independent evaluation of the MMPP pilot to assess the impact of MMPP.  Findings suggest the MMPP positively impacted practice transformation; provider satisfaction; patient satisfaction with provider communication; chronic disease management; and disparities in care by practice location.  The Medicaid results, outlined in a separate brief, where particularly notable.  MMPP reports are available at the links below 

MPP Reports:

Evaluation of the Maryland Multi-Payor Patient Centered Medical Home Program - Medicaid Program Impacts - Report

Evaluation of the Maryland Multi-Payor Patient Centered Medical Home Program - Medicaid Program Impacts - Commission Presentation

Evaluation of the Maryland Multi-Payer Patient Centered Medical Home Program - Final Report

Evaluation of the Maryland Multi-Payer Patient Centered Medical Home Program - First Annual Report.



Last Updated: 3/29/2019