The CMS ACCESS Model, Outcomes, and the Emerging Question at the Heart of Chronic Care: How Will We Prove Continuity?

When CMS releases a new model, industry insiders usually brace for a wave of webinars, FAQs, and interpretation gymnastics. The ACCESS Model skipped that ritual. It arrived with an unambiguous purpose and sent ripples through clinical, behavioral health, and social care communities almost immediately.

ACCESS, short for Advancing Chronic Care with Effective, Scalable Solutions, is CMS’s newest test of outcome-aligned payment for Medicare beneficiaries with chronic conditions like hypertension, diabetes, chronic musculoskeletal pain, and depression. These conditions are rarely shaped by a single appointment. They are shaped by everything that happens in the quieter, less visible spaces between appointments.

What makes ACCESS different from previous efforts is its explicit focus on continuous, technology-supported care. CMS wants to know whether steady engagement, remote monitoring, behavioral interventions, and timely care coordination can produce better outcomes than episodic visits alone. The goal is straightforward. Reward results that matter rather than the number of services delivered.

But once CMS tied payment to outcomes, a more complicated question emerged almost instantly. If the model depends on continuous support, how will organizations demonstrate that continuity actually happened?

That question is now defining the early conversation.

ACCESS Quietly Introduces a New Expectation: Visibility Between Visits

CMS does not use poetic language in the ACCESS materials, but the structure of the model reveals a foundational shift. To participate, organizations must be able to share structured care plans and updates electronically at key points in the patient journey, including treatment initiation, completion, and defined clinical milestones. These updates must be transmitted through a Health Information Exchange or another trusted, secure network so referring clinicians can review them and take coordinating action.

This requirement transforms continuity from an abstract idea into a documented expectation. The model also requires each participant to designate a physician Clinical Director responsible for clinical oversight. In effect, CMS is saying: continuity matters, technology matters, and the ability to exchange real updates matters.

ACCESS does not demand a single technology, database, or tracking platform. But its built-in requirements signal something important. For outcome-aligned payment to function, there must be reliable, accessible evidence that care was provided across time, not just at scheduled appointments.

The Community Conversation: Where the “Receipts” Metaphor Came From

The broader community wasted no time pointing out the practical tension in ACCESS. Several leaders commented on the early announcement using the metaphor of “receipts” to describe the kind of evidence continuous care requires. Not financial receipts. Not regulatory forms. Just small, verifiable signals that a real care interaction occurred.

A blood pressure reading from a home cuff.A behavioral health follow up call.A CHW visit to address medication access.A social support interaction that prevented decline.A telehealth check-in that headed off a crisis.

The term “receipts” appeared because people recognized that chronic care is built from hundreds of small touchpoints that rarely appear in claims data. The metaphor reflected a shared anxiety. If ACCESS rewards continuity, and if continuity depends on interactions that happen across clinical, behavioral, and social settings, how will organizations surface those interactions in a way CMS trusts?

The metaphor caught on not because it was cute, but because it distilled the underlying truth. Chronic care happens everywhere. Our data systems do not.

Proof of Continuity: The Real Challenge ACCESS Brings to the Surface

What ACCESS truly requires is not a new form, a new portal, or an elaborate technology stack. It requires proof of continuity. CMS uses more formal terms like “structured care updates,” “technology-supported care,” and “coordination with referring clinicians,” but the essence is the same. Participants must be able to demonstrate that sustained, supportive care happened.

Proof of continuity does not mean documenting every phone call or conversation. It means having enough credible evidence across the care journey to show that outcomes did not improve by accident. It also means that organizations must be able to share these care updates with the clinicians responsible for oversight.

This is where the challenge gets interesting. Continuity does not live neatly in one place.

• Clinical systems hold encounter notes and lab values

• Behavioral health systems hold treatment data and follow ups

• Remote monitoring platforms hold daily readings

• Social care systems hold referral outcomes

• Schools, shelters, EMS crews, and crisis teams hold interventions that never make it into an EHR

The events that keep patients stable are almost always distributed. ACCESS does not prescribe how to unify them. But by requiring structured updates and interoperability through HIE or equivalent, it puts pressure on states, health systems, and community networks to solve for visibility.

Is an HIE Enough? Or Will ACCESS Require Something More?

A natural question arises from the ACCESS requirements. If participants must share structured updates electronically, is a traditional HIE sufficient to serve as the continuity backbone?

The answer is: partly, but not entirely.

HIEs excel at clinical data exchange. They connect hospitals, clinics, labs, and EHRs. They can easily carry ACCESS-required updates such as treatment initiation or milestone information. But chronic care does not stop at the clinic door. For many conditions in the ACCESS scope, the most influential events occur with community partners, behavioral health providers, social care agencies, home health teams, or remote monitoring devices. Those systems often fall outside the historical footprint of HIEs.

Some states have already expanded their HIEs into broader health data utilities that include behavioral health and social care partners. Others rely on Community Information Exchanges to capture non-medical events. Some use statewide social care networks. Most use a patchwork.

ACCESS does not dictate a single model. It simply raises the question in a sharp, unavoidable way.

To succeed in a program built on continuous support, will we need a more integrated, cross-sector approach to visibility? Is it time for HIEs and CIEs to align more intentionally? Or do states need to consider a new continuity or event layer across systems?

The model does not force the answer, but it clearly forces the conversation.

The Practical Opportunity Hidden in the ACCESS Requirements

Although the ACCESS requirements may seem administrative, they contain a meaningful opportunity for the field. By requiring participants to share structured care updates and maintain HIE connectivity or equivalent secure exchange, CMS creates the scaffolding for a system that can finally see continuity across settings.

That scaffolding does not automatically create a comprehensive picture. But it offers the technical and policy foundation for progress. Organizations that already exchange data with behavioral health providers, social care partners, EMS agencies, and community networks will be ahead of the curve. Those that do not will need to rethink their infrastructure.

In this way, ACCESS becomes a quiet accelerant to the broader push toward whole-person data interoperability. It rewards outcomes that depend on coordination. It requires data sharing that supports coordination. And it places value on the kinds of supports that have long been invisible to traditional payment models.

A Turning Point for Chronic Care

The ACCESS Model is, on the surface, a clinical payment experiment. But underneath, it is a test of whether our data ecosystem can finally catch up to the reality of chronic care. It challenges the system to see the full spectrum of care interactions that shape health, especially for people with complex needs who rely heavily on behavioral health supports, social care services, and everyday guidance.

CMS did not explicitly ask for a new continuity verification system. It did not use the word “receipts.” But through its requirements for interoperability, structured care updates, clinical oversight, and shared accountability with referring clinicians, it implicitly asks: can participants demonstrate the continuous, technology-supported care that makes outcomes possible?

That is the question the industry must now answer.

ACCESS does not demand perfection. But it signals a future where visibility into care between visits is no longer optional. The scattered points of continuity across clinical, behavioral, and social sectors will need to become more coherent and more connected.

We are entering an era where outcomes matter more than encounters, and where continuity is the currency that makes those outcomes possible. ACCESS gives us the first national framework to take that seriously.

If we want to improve chronic care at scale, we need to ask the question that the ACCESS conversation has brought to the surface: do we have the visibility we need to prove the care that truly matters?

The answer, for most communities, is not yet. But ACCESS gives us a clear place to start.