Chronic disease is one of the most significant challenges in Medicare today. Patients are living longer with conditions that require ongoing support and providers are balancing the realities of limited time, fragmented systems, and growing expectations in value-based care. Against this backdrop, CMS has released the ACCESS Model, short for Advancing Chronic Care with Effective, Scalable Solutions.
This new Innovation Center model is intended to reshape how chronic care is delivered across the country.
It places a strong emphasis on proactive care, consistent engagement, and the use of scalable tools that help organizations manage and support patients throughout the year. ACCESS signals CMS’s continued movement toward models that reward ongoing care coordination and measurable improvements in patient outcomes.
At a high level, the ACCESS Model is designed to strengthen the care experience for Medicare beneficiaries who live with chronic conditions. These include diabetes, COPD, heart disease, kidney disease, and others that require long term support.
Instead of focusing solely on episodic visits, ACCESS encourages a continuous care approach that gives patients more frequent touch points and earlier interventions.
CMS wants to help providers create environments where patients feel supported month to month, where trends are identified before they become complications, and where care teams can work together with better visibility and shared information.
ACCESS is built around four core priorities.
Care that is preventive rather than reactive: This means regular outreach, coaching, monitoring, and interventions long before a condition worsens.
Care that is coordinated across settings: Primary care teams, specialists, and community providers work together with clearer communication and shared goals.
Care that is measurable: Providers must be able to show improvements in outcomes such as stability of chronic conditions, fewer avoidable events, and higher engagement.
Care that is scalable: CMS understands that successful chronic care models must grow with patient populations. ACCESS encourages solutions that are efficient, repeatable, and sustainable.
For ACOs, the ACCESS Model reinforces a trend that has been building for years. Long term success in value-based care depends on consistent, intentional chronic care management. ACCESS does not introduce an entirely new philosophy. Instead, it clarifies the path forward.
Here are the signals CMS is sending to providers.
Providers who succeed in ACCESS will be those who blend clinical expertise with strong operational systems. ACCESS rewards good care and good infrastructure working together.
ThoroughCare’s role in the ACCESS conversation is grounded in helping providers understand what meaningful, scalable chronic care looks like in practice.
The ACCESS Model establishes a national vision for proactive, coordinated, year round support for Medicare beneficiaries. ThoroughCare provides the operational foundation that helps organizations turn that vision into daily reality.
ACCESS makes clear that patients need steady engagement, care teams need shared information, and leaders need a trustworthy view of population health. Most importantly, organizations need structured workflows that scale without burning out the people who deliver care. ThoroughCare was built with these needs in mind.
To support the expectations of ACCESS, ThoroughCare brings together the essential elements of long term chronic care:
Together, these capabilities help organizations operate in a way that aligns naturally with the ACCESS Model.
Providers can deliver long term, relationship-centered care with more clarity and less administrative pressure. Patients experience more consistent support. Care teams work with better information. Leaders have the insight they need to demonstrate improvement.
ThoroughCare strengthens an organization’s ability to participate in ACCESS by making chronic care more organized, more scalable, and more impactful for the patients who need it most.