Medicare Care plan and Self- Care plans?

Transcription

1 Medicare Care plan and Self- Care plans? High Risk Ppulatin Management Pilt prject Suth Jrdan clinic Debby Evans RN, BSN, CDE Care Manager

2 Our Aging Patient Ppulatin * Flding Baby Bmer retirement. The 77 millin Baby Bmers thse brn between 1946 and 1964 after the cnclusin f Wrld War II are nearing retirement age. This will result in a significant jump in Medicare enrllment. The Cngressinal Budget Office (CBO) prjects that the number f Americans aged 65 and lder will increase by 76 percent by [12]

3 Fewer Tax Payers t supprt this ppulatin * Lnger dependence and fewer wrkers. In 1965, when Medicare was created, the average American life span was a little ver 70 years f age, but in 2030, it is prjected t reach almst 81 years.[13] In 1965, there were fur wrkers fr every retiree.[14] Tday, there are rughly three wrkers fr each Medicare beneficiary, and by 2030, that will decline t 2.3 wrkers fr each beneficiary.[15] Americans are living lnger and lnger in retirement but are supprted by fewer and fewer wrking taxpayers.

4 Lnger Enrllment in Medicare

5 High Risk and/r Medicare referrals prcess SOUTH JORDAN High Risk and/r Medicare referrals t Care Manager fr Care Plan Develpment REFERRAL TRIGGERS: Financial barriers: Self-Pay; uninsured; recent lss f jb; high deductible insurance plan; IHC FA; PCN. Cmplaints f inability t pay deductible, r ability t pay fr medicatins r recmmended testing, getting evicted frm place f residence, inability t pay utilities, fd, necessities f life. Marital status: single, divrced, widwed Recent lss: death f a lved ne r pet Over utilizatin f phne calls/r drp ins frm patient r family members t the clinic withut appintments Literacy issues: patients that say, Can yu spell that fr me?, r I dn t have my glasses, can yu write that dwn fr me? Language barriers: patients wh require interpreters fr freign languages, r sign language Md disrders: patients wh yu get the sense are distraught and/r require additinal caching, and/r time frm the Prviders. (D yu feel anxius while speaking t this patient?) Are they insisting n taking unscheduled time frm emplyees? Hw d I knw if a patient already has a Care Plan? In their prblem list in Help2, Persnalized Primary Care, and then the name f the Care Plan will shw alng with the date that the Care Plan was initiated with the patient. We have several Care Plans s a patient can have mre than ne Care Plan, addressing different diagnsis r issues. Even if the patient has a Care Plan in place, please still refer. They may have new issues arise that require additinal resurces. Hw is a referral sent t the Care Manager? In Help2 Ensure yu have imprted (ht text) caremanager - care manager referral Debby Originatin Date: Revised Date: 10/9/15

6 Patient letter * Dear Patient, As yur healthcare prvider, I want t invite yu t take advantage f the 'Welcme t Medicare' initial cmprehensive visit, a benefit available t all Medicare beneficiaries within the first 12 mnths f eligibility. The initial visit and subsequent Annual Wellness Visits (AWV) are designed t help yu and yur prvider develp a plan fr disease preventin and t maintain yur health in the cming years. The best preventive care, depends n yur wn medical past, yur family's medical histry, and hw yu live. This visit is prvided at nt cst t yu. Part f this service may include a separate appintment with ur Registered Nurse Care Manager Debby. This is a free service intended t prvide yu with valuable resurces, while assisting the prvider in meeting Medicare's requirements fr yur appintment. In additin t yur cmprehensive visit, the prvider and staff will: * Review yur cmplete health histry and screen fr depressin, fall risks and ther prblems. * Check yur bld pressure, weight, visin and activity level. * Make recmmendatins fr ther wellness services and healthy lifestyle changes. Due t the restrictins put in place by Medicare, this visit is nt intended t evaluate and manage new prblems. A separate appintment is required t evaluate and manage new cnditins. Additinally, yur prvider may require a separate appintment t evaluate and manage chrnic cnditins as a part f yur regular fllw-up care. A cpayment r deductible will be applied t prblem fcused appintments. If yu are interested in scheduling yur Welcme t Medicare appintment, please cmplete the enclsed Health Histry, Prvider/Medicatin list and Health Risk Assessment and return by mail r in persn. Once we have received yur questinnaires, yur appintment can be scheduled. We strngly encurage patients t understand their insurance benefits as cvered services vary frm plan t plan. We have als included an Advance Directive and Fact Sheet. We encurage yu t have thughtful discussin with yur family members as yu review and cmplete this frm. This imprtant dcument, helps make yur end f life wishes knwn t thers. The cmpletin f an AD is ptinal and may be returned at any time. We lk frward t assisting yu in the develpment f yur Persnalized Wellness Plan. Sincerely, Raelynn Hansen, Practice Manager Suth Jrdan Clinic

7 MEDICARE VISIT HOT TEXTS ***N appintment shuld ever be scheduled until paperwrk is returned*** Letters create as a clinical nte titled letter. Print n letterhead-psr/schedulers mcrwelcmetmedicareletter Welcme t Medicare fr all Medicare members WELCOME TO MCR = DOE wh are in first 12 mnths f eligibility mcrpreventivewellsh&uh *Preventive & Wellness cmbined fr SelectHealth 1 st AWV+Preventive SH & United Healthcare (currently nly plans we are SUBSUQUENT AWV+PREVENTIVE SH directed t prvide tgether). After first 12 mnths f eligibility mcrwellnessinvitecmm 1 ST AWV ONLY + INS NAME SUBSEQUENT AWV ONLY + INS NAME Annual Wellness nly Medicare Part B and all ther Advantage plans except SelectHealth & United Healthcare Referrals and Requests fr Care Management Team medicareapptrequest Medicare appintment request must chse apprpriate ptin based n patients insurance plan. This message is sent t Patricia Garcia by schedulers. caremanagermedicare Care Manager referral fr care plan. Sent by Patricia r prvider fr patients identified as needing extra prir t Medicare visit r PPC visit type (Depressin, DM, HTN, High Risk) Prgress Ntes Prviders Only medicarewelcmetmedicare Medicare Prgress Reprt medicareawvpreventivesh&uh Medicare Annual Wellness & Preventive fr SelectHealth Medicare Advantage Evaluatin and United Healthcare patients after first 12 mnths medicarefirstawv Medicare First Annual Wellness nly visit G0438 Medicare Wellness Assessment patients with Medicare Part B and ther Cmmercial Advantage plans except SelectHealth & United Healthcare. First Wellness after Welcme t Medicare r after first 12 mnths f eligibility. medicaresubsequentawv Medicare subsequent Wellness nly visit G0439 all Medicare Wellness Assessment subsequent visits fr Medicare Part B and ther Cmmercial Advantage plans except Select Health & United Healthcare. While sme Regence plans state they cver, schedule fr preventive alng with Wellness until further directin.

8 Care Planning and Self Care Supprt At Intermuntain Healthcare, we engage patients in wellness and preventin decisins, and in chices abut their care. Patient engagement means patients are invlved in their wn health and care chices, and they interact meaningfully with caregivers. At Intermuntain, best patient care invlves care f the whle persn. This includes mental, emtinal, and physical health, as well as lifestyle. Our Missin: Helping peple live the healthiest lives pssible. Our Visin: Patient Engagement: We prvide a cmpassinate healing experience. Fully invlving patients in clinical and financial decisins abut their healthcare, and encuraging them t take respnsibility fr healthy life chices. Yur Primary Care Prvider has asked yur Care Management Team t assist yu in yur care decisins by develping a care plan with yu. A care plan is a written persnalized plan which, under the assessment prcess, details a patient s integrated health and scial care needs. The care plan is a way f wrking ut with yu, what we are ging t d t assist yu, and allws yu t set gals t wrk tward with ur supprt. Creating a care plan with yur health, and mental health care prfessinals, means being able t talk abut yur situatin, hw it affects yur life, what yu want t d, and what yu can d fr yurself with the right supprt. It's abut being given all the infrmatin yu need, being listened t, being able t ask questins, and feeling able t say what's really imprtant t yu. The plan that is agreed upn will be the result f this prcess.

9 Medicare Care plan Assessment tls * 1.

10 * 2 PHQ-9

11 * 3 ROI

12 My Health registratin

13 Advance Directives

14 Medicare Self Care Plan. Date At yur appintment tday yu and yur healthcare team discussed yur preventive care and made a plan fr what t d next. These are ntes n what yu did and decided. The gals yu have set fr yur preventive care include: Treatment Guidelines. Yu were given a cpy f the Preventive Care fr Men/Wmen n (date): Current testing status: We reviewed yur current health status t include: 1. Risk Factrs 2. Health Checks 3. Cancer Screenings 4. Immunizatins 5. Healthy Habits Yur Preventive Fact Sheet was cmpleted n: Self-Management. We discussed sme changes t help yu manage yur preventive care needs and reach yur health care needs. Hw imprtant are these changes t yu? (1-10): What wuld help yu mve frm a t a? Hw cnfident are yu that yu can make these changes? (1-10): What wuld help yu mve frm a t a? Hw can yu healthcare team help yu with yur gals? - Self-care gals and mnitring: See page 4 Patient Educatin and Cmmunity Resurces. Resurces: Medicare Annual Wellness Visit Living Well with Chrnic Cnditins 55 + Senir Resurce Directry My Health On-line Brchure Advance Directives Educatin/Brchure Persnalized Primary Care Brchure Self Care frm A-Z Intermuntain Medical Grup Prvider List Medicare Calendar with next year s appintment Senir Citizen Senir Centers Financial Assistance Medicatin Assistance Mental Health Needs Release f Infrmatin Signed Nurse Care Manager: Health Care Advcate: Clinic Phne Clinic Fax

15 Our patients: Age Insurance CM appt Date f care plan cmpletin Prvider Date f Dr appt Marital Status 73 MCR Cmplete Optum l/m, then discnnected phne Dr. Sheldn Jhnsn 8/11/2015 8:00 Widwed 72 MCR Cmplete Optum 8/14/ :00 8/14/2015 Dr. Jhn Richards 11:00 Widwed 65 MEDICARE COMPLETE OPTUM 10:00 9/1/2015 Dr. Jhn Richards 11:00 Married 68 SH Medicare 10:00 11/11/2015 Dr. Jhn Richards 8:00 Married 64 MEDICARE COMPLETE OPTUM 10:00 10/26/2015 Kim Winegar FN-P 8:00 Married 87 Medicare SH+UHC 10:00 10/9/2015 Dr. Sheldn Jhnsn 9:30 Married 90 Medicare SH+UHC 2:00 10/8/2015 Dr. Sheldn Jhnsn 2:30 Married 66 MEDICARE COMPLETE OPTUM 2:00 11/10/2015 Dr. Jhn Richards 10:00 Married 72 MEDICARE COMPLETE OPTUM 10:00 Kim Winegar FN-P 2:00 Married 58 MCR Utah 11/12/ /12/2015 Dr. Patrick Marcrft 2:00 Divrced 73 MEDICARE COMPLETE OPTUM 2:00 Dr. Jhn Richards 8:00 Married 69 SH Medicare +UHC 10:00 Dr. Jhn Richards 8:00 Married 68 Medicare, AARP L/M 12/1/2015 Dr. Jhn Richards 8:00 Married 64 MCR Utah 11:00 Dr. Jhn Richards 11:00 Divrced 71 Medicare/SH Medicaid 2:00 Dr. Ryan Jnes 2:00 Married 76 SH Medicare 10:00 Dr. Jhn Richards 8:30 Married 67 SH and UHC Medicare L/M Dr. Jhn Richards 8:00 Married 74 SelectHealth and United HealthL/M Dr. Jhn Richards 8:00 Married 72 MCR and PEHP 11:00 Dr. Ryan Jnes 2:00 Married

16 Dcumentatin * Dr., Pt added the fllwing dx t her prblem list fr yur review if yu wuld like t add: 1. Depressin 2. Anxiety 3. Insmnia 4. GERD 5. Right breast cancer. * Pt reprts her main cncerns are the fllwing: 1. Being the caregiver fr her Husband wh has Parkinsn s Disease. 2. Financial stressrs, n pensin fr either she nr her Husband and is wrried that their mney will nt last until they die. 3. Many recent family and friends deaths, natural, suicide r cancer. 4. Upset abut her being verweight. 5. Main sx cmplaint f abdminal pain and acid reflux. 6. Shrt term memry lss.

17 Dcumentatin * Patient met with CM t develp her Medicare Care plan/self care plan n 8/14/2015 Husband died 7 years ag in April. Pt has nt had any grief cunseling. Pt is having truble sleeping. Pt. reprts that she is wrried abut bruising a lt. Her Granddaughter tripped her and she fell hurting her left great te. Has a hard time cncentrating, making decisins, cannt rganize like she used t be able t which is upsetting t her. She reprts that she will need a refill Rx fr her Xanax t use prn. Reviewed prblem list with her and she said that she has had her bilateral breast implants remved, knee replacements x2, and cataract is in her OD. She had a Dexa scan at her wrk 10 years ag. Review f medicatins, changed Caltrate 600+ t a One a Day MVI per recmmendatin f Dr. Oz n TV. Debby Evans RN, BSN, CDE Care Manager

18 Medicare Care plan/self-care plan Questinnaire Patient Satisfactin 1. On a scale f 1-5, hw wuld yu rate yur experience in meeting t develp yur care plan t prepare fr yur Medicare Wellness visit? 5, 5,5 2. On a scale f 1-5, did yu find this interventin f assistance t facilitate yur needs/questins/ r cncerns in preparatin t meeting with yur Dr.? 5, 5,5 3. Wuld yu recmmend this Medicare Care Plan appintment t thers? Yes, Yes, Yes 4. What added value did yu perceive yu gained in this meeting t create yur Medicare Care plan? It made me feel that the Dr. was mre cncerned abut me mre than a nrmal visit. I knew that the Care Manager wuld have mre time t answer my questins in depth, s that I culd give mre time t the Dr. t give t his ther patients. I enjyed the feeling that we did nt have t rush, and that we were cared fr. It is nice t have an in between persn and I am cnfident knwing that I can call yu if I need yu and yu will get right back t me. 5. Any suggestins t make this prcess f mre value t yu r thers? N, I dn t think s. I thught it was great.

19 Sent: Friday, Nvember 13, :15 AM T: Debby Evans Subject: Self Care frm A-Z Debby, My wife and I are impressed with the medical bk yu gave me: "Self Care frm A - Z" Is there any chance we culd purchase five f them? We wuld like t give ne t each f ur kids. Thank yu,

20 Prviders satisfactin * Dr. Patrick Marcrft: This really streamlines ur Medicare visits. * Dr. Jhn Richards: This has been really helpful because I knw the infrmatin has been reviewed, and I d nt have t re-enter it. I lk up what Debby has put in her nte at the tp f the visit nte t knw what t fcus n. I am still in the bservatin mde t see hw we can refine this prcess even mre. This saves me time.

21 Medicare Self care plan

22 References * [12] Cngressinal Budget Office, The 2015 Lng-Term Budget Outlk, p. 52. * [13] U.S. Census Bureau, Natinal Ppulatin Prjectins, Summary Table 10, 2008, summarytables.html (accessed July 24, 2015). * [14] Scial Security Administratin, Rati f Scial Security Cvered Wrkers t Beneficiaries, Calendar Years , (accessed July 22, 2015). * [15] Centers fr Medicare and Medicaid Services, 2014 Annual Reprt f the Bards f Trustees f the Federal Hspital Insurance and the Federal Supplementary Medicare Insurance Trust Funds, p. 67, Reprts/ReprtsTrustFunds/dwnlads/tr2014.pdf (accessed July 24, 2015). * Issue Brief #4448 n Health Care July 30, 2015 Medicare at 50: Refrm Will Better Serve Senirs Health Care Needs By Rbert E. Mffit, Ph.D.

23 Questins?