Clinical Tracks
ACCESS focuses on four clinical tracks addressing many of the most common chronic conditions affecting more than two-thirds of people with Medicare.
Each track groups related conditions that are commonly treated using similar types and levels of care. Participating organizations are responsible for managing all qualifying conditions in a track, supporting integrated, patient-centered care.
Track Structure
Each track includes condition-specific measures and outcome targets informed by clinical guidelines — such as patient improvement or control in biomarkers like blood pressure, HbA1c, lipids, or weight, or in validated Patient Reported Outcome Measures (PROMs) of pain, mood, and function.
Outcome Measures Summary
The following table summarizes qualifying conditions and outcome measures for each clinical track:
| Track | Qualifying Conditions | Outcome-Aligned Payment Measures |
|---|---|---|
| eCKM | Hypertension, OR two or more of: dyslipidemia, obesity/overweight with central obesity, prediabetes | Control or minimum improvement in blood pressure (BP), lipids, weight, and HbA1c |
| CKM | One or more of: diabetes mellitus, chronic kidney disease (CKD), atherosclerotic cardiovascular disease (ASCVD) | Control or minimum improvement in BP, lipids, weight, and HbA1c; [CKD and diabetes only] Submission of eGFR and UACR data |
| MSK | Chronic musculoskeletal pain | Minimum improvement in pain intensity, interference, and overall function (assessed via validated PROM) |
| BH | One or more of: depression, anxiety | Minimum improvement in symptoms (PHQ-9 for depression, GAD-7 for anxiety); Submission of WHODAS 2.0 12-item functional assessment |
Clinical Definitions
- Outcome targets are guideline-based and defined in consultation with clinical experts. "Control" refers to meeting guideline-directed targets.
- Obesity is defined as BMI ≥ 30. Overweight is defined as BMI 25–29.99 along with a marker of central obesity (waist circumference > 40 inches/102 cm for men or > 35 inches/88 cm for women).
- Chronic kidney disease includes Stage 3a and 3b only.
- Chronic pain is defined as pain lasting more than three months. Musculoskeletal disorders include conditions affecting bones, joints, muscles, and connective tissues.
Early Cardio-Kidney-Metabolic (eCKM)
Early Cardio-Kidney-Metabolic (eCKM)
Focuses on early-stage metabolic conditions before they progress to more serious diseases. Early intervention can prevent progression to diabetes, heart disease, and kidney disease.
eCKM Eligibility
Patients qualify for eCKM with hypertension alone, OR with two or more of the following: dyslipidemia, obesity (BMI ≥ 30) or overweight (BMI 25–29.99) with central obesity marker, or prediabetes.
eCKM Outcome Measures
The eCKM track measures outcomes including:
- Blood pressure reduction — Achieving target blood pressure levels or clinically meaningful reductions
- Lipid management — Improvement in cholesterol levels (LDL, HDL, triglycerides)
- Weight management — Percentage body weight loss or reduction in waist circumference
- Prediabetes control — Prevention of progression to Type 2 diabetes, HbA1c improvement
Who Benefits
Patients with early-stage metabolic conditions who can benefit from lifestyle modifications, remote monitoring, and technology-supported coaching to prevent disease progression.
Cardio-Kidney-Metabolic (CKM)
Cardio-Kidney-Metabolic (CKM)
Addresses established cardiometabolic and kidney conditions requiring ongoing management. Focus is on disease control, complication prevention, and improved quality of life.
CKM Outcome Measures
The CKM track measures outcomes including:
- Glycemic control — HbA1c improvement or maintenance at target levels
- Kidney function — Stabilization or improvement of eGFR, reduction in albuminuria
- Cardiovascular risk — Blood pressure control, lipid management, reduced cardiovascular events
- Medication adherence — Appropriate use of guideline-directed therapies
Who Benefits
Patients with established diabetes, CKD, or cardiovascular disease who need comprehensive, coordinated management to control their conditions and prevent complications.
Musculoskeletal (MSK)
Musculoskeletal (MSK)
Targets chronic musculoskeletal pain conditions with a focus on functional improvement and pain reduction through multimodal, non-pharmacological approaches.
MSK Outcome Measures
The MSK track measures outcomes including:
- Pain reduction — Clinically meaningful improvement on validated pain scales
- Functional improvement — Enhanced mobility, physical function, and daily activities
- Quality of life — Patient-reported outcome measures (PROMs) for overall wellbeing
- Reduced opioid dependence — Decreased reliance on opioid medications where applicable
Who Benefits
Patients with chronic musculoskeletal pain who can benefit from physical therapy, exercise programs, behavioral interventions, and technology-supported self-management.
Behavioral Health (BH)
Behavioral Health (BH)
Addresses common mental health conditions through technology-enabled therapy, coaching, and support services that complement traditional behavioral health care.
BH Outcome Measures
The BH track measures outcomes including:
- Depression improvement — Reduction in PHQ-9 scores or achievement of remission
- Anxiety reduction — Improvement in GAD-7 scores
- Functional status — Improved daily functioning and social engagement
- Treatment engagement — Sustained participation in care and therapy
Who Benefits
Patients with depression and/or anxiety who can benefit from digital therapeutics, app-based cognitive behavioral therapy (CBT), remote counseling, and technology-supported behavioral health services.
Care Delivery Across All Tracks
Flexible Care Models
ACCESS care organizations can deliver care through multiple modalities — in-person, virtually, asynchronously, or through other technology-enabled methods as clinically appropriate.
ACCESS care organizations are expected to offer integrated, technology-supported care that may include:
- Clinician consultations — Virtual and in-person visits with physicians, nurses, and specialists
- Lifestyle and behavioral support — Nutrition counseling, exercise programs, smoking cessation
- Therapy and counseling — Mental health services, pain management counseling
- Patient education — Disease education and self-management training
- Care coordination — Communication with PCPs and other providers
- Medication management — Prescription management and adherence support
- Diagnostic services — Ordering and interpreting tests and imaging
- Device monitoring — FDA-authorized devices, wearables, and remote monitoring
Payment Structure by Track
Most tracks include an initial year of care followed by an optional continuation period at a reduced rate, facilitating continued patient support after initial improvement goals are met.
| Track | Initial Period | Continuation Available |
|---|---|---|
| eCKM | 12 months | Yes, reduced rate |
| CKM | 12 months | Yes, reduced rate |
| MSK | 12 months | Yes, reduced rate |
| BH | 12 months | Yes, reduced rate |
Rural Adjustment
To promote access in underserved areas, a fixed adjustment will be applied to rural patients in qualifying tracks.
Multi-Track Participation
Organizations can participate in multiple clinical tracks if they meet the requirements for each. This allows comprehensive care organizations to address multiple conditions for their patient population.
Can an organization participate in all four tracks?▼
Yes, organizations can apply to participate in one or more clinical tracks, provided they meet the eligibility and capability requirements for each track they wish to offer. Organizations must demonstrate clinical expertise and infrastructure for each track.
Can a patient be enrolled in multiple tracks?▼
Yes, if a patient has qualifying conditions in multiple tracks, they can receive care through multiple tracks simultaneously. Organizations are responsible for coordinating care across tracks.
Will CMS add more tracks in the future?▼
CMS may consider additional tracks and conditions in the future based on model performance and emerging evidence for technology-supported care in other condition areas.
Next Steps
Understand How Payments Work
Learn about Outcome-Aligned Payments and how performance is measured
Check Your Eligibility
See the requirements for participating in ACCESS clinical tracks