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In the CPC+ Model, participating practices were required, for example, to use a two-step risk stratification process for all empaneled patients, addressing medical need, behavioral diagnoses, and health-related social needs and define at least one subpopulation of patients with specific complex needs, develop capabilities necessary to better address ( those needs, and measure and improve the quality of care and utilization of this subpopulation. [73] Central to the delivery of advanced primary care is the organization of the practice into care teams that have the data they need to manage their patient populations and that have time allocated to plan and implement practice improvement strategies

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