2017 Physician Fee Schedule Impact on Medicare ACOs REGULATORY UPDATES

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1 2017 Physician Fee Schedule Impact on Medicare ACOs REGULATORY UPDATES

2 2017 Physician Fee Schedule Impact on Medicare ACOs 1. Allowing ACO Participants to report PQRS separately from ACO 2. ACO Quality Measure Reporting 3. Alignment with Quality Payment Program 4. Beneficiary Preferences and ACO Assignment 5. Chronic Care Management (CCM) Updates

3 ACO Participants who report PQRS measures separately REGULATORY UPDATES

4 ACO Participants who report PQRS quality measures separately After consideration of the comments received regarding CMS proposed policies for EPs and group practices participating in ACOs that report PQRS quality measures separately from the ACO, CMS is finalizing the policies as proposed. At (j)(1)(ii), CMS is finalizing its proposal to establish a secondary PQRS reporting period for the 2017 PQRS payment adjustment for individual EPs or group practices who bill under the TIN of an ACO participant if the ACO failed to report on behalf of such individual EPs or group practices during the previously established reporting period for the 2017 PQRS payment adjustment.

5 ACO Participants who report PQRS quality measures separately This option is limited to EPs and group practices that bill through the TIN of an ACO participant in an ACO that failed to satisfactorily report on behalf of its EPs and would not be available to EPs and group practices that failed to report for purposes of PQRS outside the Shared Savings Program; e.g. not in an ACO. CMS is finalizing its proposal that these affected EPs may utilize the secondary reporting period either as an individual EP or as a group practice using one of the registry, QCDR, direct EHR product, or EHR data submission vendor reporting options. CMS is are also finalizing its proposal that such EPs do not need to register for the PQRS GPRO for the 2017 PQRS payment adjustment.

6 ACO Participants who report PQRS quality measures separately In addition, CMS is finalizing at (j)(4)(v) its proposal that sections (j)(8)(ii), (iii), and (iv) would apply to affected EPs reporting as individuals using this secondary reporting period for the 2017 PQRS payment adjustment. Further, CMS is finalizing at (j)(7)(viii) its proposal that sections (j)(9)(ii), (iii), and (iv) would apply to affected EPs reporting as group practices using this secondary reporting period for the 2017 PQRS payment adjustment.

7 ACO Participants who report PQRS quality measures separately CMS is finalizing its proposal that the secondary reporting period for the 2017 PQRS payment adjustment would coincide with the reporting period for the 2018 PQRS payment adjustment (that is, January 1, 2016 through December 31, 2016). In addition, CMS is finalizing a policy under which CMS will assess the individual EP or group practice s 2016 data using the applicable satisfactory reporting requirements for the 2018 PQRS payment adjustment (including, but not limited to, the applicable PQRS measure set). If an affected individual EP or group practice decides to use the secondary reporting period for the 2017 PQRS payment adjustment, the EP or group practice should expect to receive a PQRS payment adjustment for services furnished in 2017 until CMS is able to determine that the EP or group practice satisfactorily reported for purposes of the 2017 PQRS payment adjustment. Further, CMS is finalizing its proposal that the informal review submission periods for these EPs or group practices would occur during the 60 days following the release of the PQRS feedback reports for the 2018 PQRS payment adjustment.

8 2017 ACO Quality Measure Reporting REGULATORY UPDATES

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12 GPRO Web Interface Added/Removed Added: Medication Reconciliation Post Discharge Removed: Removed: Removed: Removed: Medication Documentation PREV -11 Blood Pressure Coronary Artery Disease (CAD) Heart Failure (HF)

13 Medication Reconciliation Post Discharge NQF #0097 The percentage of discharges from any inpatient facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) for patients 18 years and older of age seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record. file:///c:/users/administrator/downloads/2016_pqrs_measure_046_11_17_2015.pdf.pdf

14 Medication Reconciliation Post Discharge Definition: Medication Reconciliation A type of review in which the discharge medications are reconciled with the most recent medication list in the outpatient medical record. Documentation in the outpatient medical record must include evidence of medication reconciliation and the date on which it was performed.

15 Medication Reconciliation Post Discharge Any of the following evidence meets criteria: (1) Documentation of the current medications with a notation that references the discharge medications (e.g., no changes in meds since discharge, same meds at discharge, discontinue all discharge meds), (2) Documentation of the patient s current medications with a notation that the discharge medications were reviewed, (3) Documentation that the provider reconciled the current and discharge meds, (4) Documentation of a current medication list, a discharge medication list and notation that the appropriate practitioner type reviewed both lists on the same date of service, (5) Notation that no medications were prescribed or ordered upon discharge

16 Claims Based Added/Removed Added: ACO-44 Use of Imaging Studies for Low Pack Pain Added: ACO-43 Ambulatory Sensitive Condition Acute Composite Removed: ACO 9 Ambulatory Sensitive Conditions Admissions: COPD or Asthma in Older Adults Removed: ACO 10 Ambulatory Sensitive Conditions Admissions: Heart Failure (HF)

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18 Prevention Quality Acute Composite Description Prevention Quality Indicators (PQI) composite of acute conditions per 100,000 population, ages 18 years and older. Includes admissions with a principal diagnosis of one of the following conditions: dehydration, bacterial pneumonia, or urinary tract infection.

19 Numerator Discharges, for patients ages 18 years and older, that meet the inclusion and exclusion rules for the numerator in any of the following PQIs: PQI #10 Dehydration Admission Rate PQI #11 Bacterial Pneumonia Admission Rate PQI #12 Urinary Tract Infection Admission Rate Discharges that meet the inclusion and exclusion rules for the numerator in more than one of the above PQIs are counted only once in the composite numerator. Denominator Population ages 18 years and older in metropolitan area or county. Discharges in the numerator are assigned to the denominator based on the metropolitan area or county of the patient residence, not the metropolitan area or county of the hospital where the discharge occurred. Conditions treatable in outpatient setting

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21 ACO Alignment with Quality Payment Program WHAT YOUR MEDICARE ACO NEEDS TO KNOW ABOUT MACRA 11/14/

22 Quality Payment Program The Quality Payment Program will reform Medicare Part B payments for more than 600,000 clinicians. Clinicians will choose how they want to participate in the Quality Payment Program based on their practice size, specialty, location or patient population. Alternative Payment Model (APM) Advanced APM Merit-based Incentive Payment System (MIPS) 11/14/

23 MIPS or APM or Advanced APM 11/14/

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25 Who participates in MIPS? MIPS Participants Medicare Part B clinicians billing more than $30,000 a year AND providing care for more than 100 Medicare patients per year Physicians Nurse Practitioners Physician Assistants Clinical Nurse Specialists Certified Registered Nurse Anesthetists 11/14/

26 Who is excluded from MIPS? Excluded from MIPS Clinicians below the low-volume threshold Medicare Part B clinicians billing less than or equal to $30,000 a year OR 100 or fewer Medicare Part B patients. Clinicians in an Advanced APM Newly-enrolled Medicare clinicians. Clinicians who enroll in Medicare for the first time during a performance period are exempt from reporting on measures and activities for MIPS until the following performance year. 11/14/

27 What are Medicare ACOs? APM Shared Savings Program Track 1 Shared Savings Program Track 2 and 3 Advanced APM Next Generation ACO Advanced APM MIPS eligible clinicians in ACOs are subject to MIPS under the APM scoring standard All MIPS eligible clinicians in the APM Entity are considered a group and will receive the same score Participating eligible clinicians who are determined to be Qualifying APM Participants are exempt from MIPS. Participating eligible clinicians who are determined to be Qualifying APM Participants are exempt from MIPS. 11/14/

28 Pick your pace for participation in the MIPS transitional year 2017 Participate in an Advanced Alternative Payment Model [Excluded from MIPS] Comprehensive List: ced_apms_in_2017.pdf Test Pace MIPS Partial Year MIPS Full Year Submit some data after January 1, Neutral or small payment adjustment Report for 90 day period after January 1, 2017 Small positive payment adjustment Fully participate starting January 1, 2017 Modest positive payment adjustment Not participating in the Quality Payment Program for the transition year 2017 will result in a negative 4% payment adjustment 11/14/

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45 Table 14: APM Entity Submission Method for each MIPS Performance Category Quality Cost Improvement Activities APM Entity group submits quality measure data to CMS as required under the APM. ACOS use GPRO No data submitted by APM Entity group to MIPS No data submitted by APM Entity group to MIPS UNLESS the assigned score at the MIPDS APM level does not represent the maximum improvement activities score, in which case the APM Entity may report additional improvement activities using a MIPDS data submission mechanism. Advancing Care Information Shared Savings Program ACO participant TINs submit data using a MIPS data submission mechanism. Next Generation ACO Model and other MIPS APM eligible clinicians submit data at either the individual level or at the TIN level using the MIPS data submission mechanism. 11/14/

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47 Advancing Care Information Performance Category 1. CEHRT. Use CEHRT for the performance period. 2. Report MIPS Advancing Care Information Objectives and Measures. Report the numerator (of at least one) and denominator, or yes/no statement as applicable, for each required measure; or Report a null value for each required measure that includes a null value as an acceptable result in the measure specification. 3. Support information exchange and the prevention of health information blocking and engage in activities related to supporting providers with the performance of CEHRT. 4. Implemented in a manner that allowed for the timely, secure and trusted bi-directional exchange of structured electronic health information with other health care providers, including unaffiliated providers, and with disparate certified EHR technology and health IT vendors. 11/14/

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59 How does Health Endeavors help MIPS APMs with MACRA? Quality Group Practice Reporting Option (GPRO) Advancing Care Clinical Information Reconciliation Chronic Care Management (CCM) Patient-Generated Health Data Chronic Care Management (CCM) Patient Empowerment Portal Patient-Specific Education Patient Empowerment Portal Provide Patient Access Patient Empowerment Portal Secure Messaging Patient Empowerment Portal Send a Summary of Care Record Request/Accept Summary of Care Measure Chronic Care Management (CCM) Patient Empowerment Portal View, Download and Transmit (VDT) Chronic Care Management (CCM) Patient Empowerment Portal 11/14/

60 Beneficiary Preferences and ACO Assignment PATIENT ALIGNMENT 11/14/

61 Beneficiary Preferences and ACO Assignment Because of uncertainty inherent in FFS Medicare where there is no beneficiary lock-in or enrollment, both patient advocacy groups and ACOs have expressed interest in and support for enhancing claimsbased assignment of beneficiaries to ACOs by taking into account beneficiary attestation regarding the healthcare provider that they consider to be responsible for coordinating their overall care.

62 Basic assignment methodology. * * * * * (e) For performance year 2018 and subsequent performance years, if a system is available to allow a beneficiary to designate a provider or supplier as responsible for coordinating their overall care and for CMS to process the designation electronically, CMS will supplement the claims-based assignment methodology described in this section with information provided by beneficiaries regarding the provider or supplier they consider responsible for coordinating their overall care. Such designations must be made in the form and manner and by a deadline determined by CMS. (1) Notwithstanding the assignment methodology under paragraph (b) of this section, beneficiaries who designate an ACO professional participating in an ACO as responsible for coordinating their overall care are prospectively assigned to that ACO, regardless of track, annually at the beginning of each benchmark and performance year based on available data at the time assignment lists are determined for the benchmark and performance year.

63 (2) Beneficiaries will be added to the ACO s list of assigned beneficiaries if all of the following conditions are satisfied: The beneficiary must have had at least one primary care service during the assignment window as defined under with a physician who is an ACO professional in the ACO who is a primary care physician as defined under or who has one of the primary specialty designations included in paragraph (c) of this section. The beneficiary meets the eligibility criteria established at (a) and must not be excluded by the criteria at (b). The exclusion criteria at (b) apply for purposes of determining beneficiary eligibility for alignment to ACOs under all tracks based on the beneficiary s designation of an ACO professional as responsible for coordinating their overall care under paragraph (e) of this section

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65 (2) Beneficiaries will be added to the ACO s list of assigned beneficiaries if all of the following conditions are satisfied: The beneficiary must have designated an ACO professional who is a primary care physician as defined at , a physician with a specialty designation included at paragraph (c) of this section, or a nurse practitioner, physician assistant, or clinical nurse specialist as responsible for coordinating their overall care. If a beneficiary has designated a provider or supplier outside the ACO who is a primary care physician as defined at , a physician with a specialty designation included at paragraph (c) of this section, or a nurse practitioner, physician assistant, or clinical nurse specialist, as responsible for coordinating their overall care, the beneficiary will not be added to the ACO s list of assigned beneficiaries for a performance year under the assignment methodology in paragraph (b) of this section.

66 (3) The ACO, ACO participants, ACO providers/suppliers, ACO professionals, and other individuals or entities performing functions and services related to ACO activities are prohibited from providing or offering gifts or other remuneration to Medicare beneficiaries as inducements for influencing a Medicare beneficiary s decision to designate or not to designate an ACO professional under paragraph (e) of this section. The ACO, ACO participants, ACO providers/suppliers, ACO professionals, and other individuals or entities performing functions and services related to ACO activities must not, directly or indirectly, commit any act or omission, nor adopt any policy that coerces or otherwise influences a Medicare beneficiary s decision to designate or not to designate an ACO professional as responsible for coordinating their overall care under paragraph (e) of this section, including but not limited to the following: (i) Offering anything of value to the Medicare beneficiary as an inducement to influence the Medicare beneficiary s decision to designate or not to designate an ACO professional as responsible for coordinating their overall care under paragraph (e) of this section. Any items or services provided in violation of paragraph (e)(3) will not be considered to have a reasonable connection to the medical care of the beneficiary, as required under (a)(2). (ii) Withholding or threatening to withhold medical services or limiting or threatening to limit access to care.

67 2017 Chronic Care Management (CCM) Program REGULATORY UPDATES & HEALTH ENDEAVORS CCM PROGRAM

68 New Medicare Payment for CCM Beginning January 1, 2015, Medicare now pays for chronic care management, or CCM. As detailed below, CCM payments will reimburse practitioners for furnishing specified non-face-to-face services to qualified beneficiaries over a calendar month. Specifically, CMS has adopted CPT for Medicare CCM services, which is defined in the CPT Professional Codebook as follows: Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive care plan established, implemented, revised, or monitored.

69 E/M Visit G0506 Add-on Code OR G0505 Add-on Code AND Prolonged Service Codes Total Billing Initiating Visit Start Face-to-Face Initiating Visit Initiation during an Annual Wellness Visit (AWV), Initial Preventive Physical Examination (IPPE or Welcome to Medicare Visit), face-to-face E/M visit (Level 4 or 5 visit not required), for new patients or patients not seen within 1 year prior to the commencement of chronic care management (CCM) services. The face-to-face visit is NOT a component of the CCM service, and thus may be billed separately. G0506 Add-on Code. Comprehensive assessment of and care planning by the physician or other qualified health care professional for patients requiring chronic care management services, including assessment during the provision of a face-toface service. This add-on code is to be listed separately in addition to the primary service and billed separately from monthly care management services. The projected payment rate for G0506 is $63.68 (non-facility) and $46.15 (facility).

70 E/M Visit G0506 Add-on Code OR G0505 Add-on Code AND Prolonged Service Codes Total Billing Initiating Visit Add-On Code G0506 Additional work of the billing practitioner in personally performing a faceto-face assessment Acknowledging complaints that the time spent developing the CCM-required care plan currently is not reimbursed, CMS proposes to pay physicians for care plan development under a new code, G0506. The agency proposes the following description for this code: Comprehensive assessment of and care planning by the physician or other qualified health care professional for patients requiring chronic care management services, including assessment during the provision of a face-to-face service. This add-on code is to be listed separately in addition to the primary service and billed separately from monthly care management services. The projected payment rate for G0506 is $63.68 (non-facility) and $46.15 (facility).

71 E/M Visit G0506 Add-on Code OR G0505 Add-on Code AND Prolonged Service Codes Total Billing Initiating Visit Prolonged Prolonged E/M Service Codes CCM and Complex CCM reimburse providers for clinical staff time spent providing care management services, not time spent by physicians. Recognizing the additional resource costs involved in spending an extraordinary amount of time outside the office visit caring for an individual patient s needs, CMS proposes to make payment under two codes: CPT Prolonged E/M service before and/or after direct patient care, first hour CPT Prolonged E/M service before and/or after direct patient care, each additional 30 minutes (listed separately in addition to CPT 99358) In discussing these services, CMS warns the time counted for these codes must be beyond the usual service time for the primary or companion E/M code that is also billed; no time can be counted more than once toward the provision of CPT 99358, 99359, and any other service reimbursable under the Medicare Physician Fee Schedule. The projected payment rate for is $ (facility and non-facility); for 99359, it is $54.38 (facility and non-facility).

72 Care Plan Development Addon Code G0506 Payment to physicians for care plan development under new code, G0506. G0505 companion code plus Non-Face-to-Face Prolonged E/M Services and Extraordinary amount of time outside the office visit caring for an individual patient s needs. Comprehensive assessment of and care planning by the physician or other qualified health care professional for patients requiring CCM services, including assessment during the provision of a faceto-face service. The projected payment rate is $63.68 (non-facility) and $46.15 (facility) prolonged E/M service before and/or after direct patient care, 60 minutes prolonged E/M service before and/or after direct patient care, each additional 30 minutes after Same or different day Projected payment rate for is $ (facility and non-facility and for is $54.38 (facility and non-facility) Same or different day

73 E/M Visit G0506 Add-on Code $63.68 Total Billing Initiating Visit Same Day or Different Day E/M Visit G0505 Addon Code $ minutes $ each additional 30 minutes $54.38 Total Billing Initiating Visit

74 Next Confirm Patient CCM Eligible 2+ Chronic Conditions expected to last at least 12 months (or until death that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. CMS has not mandated a definitive list of chronic conditions for purposes of CCM. Health Endeavors generally uses

75 Next Verbal Consent Documented Inform the beneficiary of the availability of CCM services; that only one practitioner can furnish and be paid for these services during a calendar month; and of their right to stop the CCM services at any time (effective at the end of the calendar month) Document in the beneficiary s medical record that the required information was explained and whether the beneficiary accepted or declined the services. Next Co-pay Discussion Verify Supplement Payment Collect Monthly Waiver of Co-pay for indigent patients

76 Structured EHR Technology Structured Recording of Patient Information Using Certified EHR Technology Structured recording of demographics, problems, medications and medication allergies using certified EHR technology. A full list of problems, medications and medication allergies in the EHR must inform the care plan, care coordination and ongoing clinical care

77 24/7 Access 24/7 Access & Continuity of Care Provide 24/7 access to physicians or other qualified health care professionals or clinical staff including providing patients/caregivers with a means to make contact with health care professionals in the practice to address urgent needs regardless of the time of day or day of week. Continuity of care with a designated member of the care team with whom the beneficiary is able to schedule successive routine appointments.

78 Initial Care Plan Initial Care Plan developed by billing practitioner Comprehensive Care Plan Creation, revision and/or monitoring (as per code descriptors) of an electronic patient-centered care plan based on a physical, mental, cognitive, psychosocial, functional and environmental (re)assessment and an inventory of resources and supports; a comprehensive care plan for all health issues. Must at least electronically capture care plan information, and make this information available timely within and outside the billing practice as appropriate. Share care plan information electronically (can include fax) and timely within and outside the billing practice to individuals involved in the beneficiary s care. A copy of the plan of care (in any form) must be given to the patient and/or caregiver.

79 Request Staffing Request Patient Case Management Services

80 minutes Chronic care management (CCM) services under CPT code (Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health professional, per calendar month, with the following required elements: Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; Comprehensive care plan established, implemented, revised, or monitored.

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82 99487 Complex CCM 60 minutes CPT code Complex chronic care management services, with the following required elements: Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; Establishment or substantial revision of a comprehensive care plan; Moderate or high complexity medical decision making; 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.

83 99489 Complex CCM Each additional 30 minutes after initial 60 minutes CPT code Each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure).

84 RHC RHC Supervision After considering the comments, we are finalizing this policy to revise (a)(5) and (a)(5) to state that services and supplies furnished incident to CCM and TCM services can be furnished under general supervision of a RHC or FQHC practitioner.

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90 Operational Workflow #1 Schedule face-to-face initiating visit. Check for 2+ chronic conditions and identify chart as CCM Eligible with sticker or electronic methodology. Include Health Endeavors CCM Patient Brochure in chart for visit. #6 Health Endeavors verify no other provider billing or transitional care codes using claims data. #7 Health Endeavors commence CCM Basic (20 minutes) and Complex Services (60 minutes plus 30 minutes). #2 At face-to-face initiating visit obtain patient verbal consent and conduct copay discussion using Health Endeavors CCM Patient Brochure to guide the conversation. Note the verbal consent in patient chart. #5 Request Health Endeavors CCM Services via Health Endeavors Portal. Must complete all mandatory fields. #8 Health Endeavors staff onsite in clinic or offsite call centers located in Omaha, NE and Phoenix, AZ Must have at least 100 consents and 500 total potential eligible patients for Health Endeavors to staff program. #3 Conduct and bill face-to-face initiating E/M visit and Add-On or Prolonged Service Codes (depending on time spend with patient. #4 Create plan of care in EHR. Health Endeavors must have access to EHR for each CCM patient. #9 For clinic staff access to Health Endeavors events and reporting tools setup patient match API/Single Sign-On.

91 Conduct Monthly Assessment Identify patient needs on a monthly basis for Referrals/Orders, Appointments and Prescription Renewal using Care Coordination Patient Needs Assessment Template (Monthly Assessment). Health Endeavors communicate Monthly Assessment to clinic nurse manager via fax or secure on a daily basis. Alternative clinic provide point of contact to set appointments, provider referrals/orders and prescription renewal. Health Endeavors may be granted access to schedule appointments in clinic scheduling system (optional). Patient Phone Intervention with clinical staff Review Monthly Assessment with Patient. Complete assigned template for month; e.g. Fall Screening, medication reconciliation, immunization reminder, etc. 3 attempts made each month. Voice message left with #800 return number. Call made on behalf of Assigned Provider. Area Code masking to local area code available upon request. Patient Empowerment Portal (MACRA Compliance) Online Chat with clinical staff Monthly Things to Complete - Online Screenings (Customizable Templates) Things to Complete /Text Message reminders Patient Disease-Specific Education with interactive quizzes Measurable Goal Setting Templates (Intervention Templates) Continuity of Care Record/Document transfer from EHR to patient (Clinical Summary)

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97 Benefits of CCM Patient Case Management Quality Measure Completion ACO Shared Savings Revenue Generation Improve Patient Experience Improve Patient Health Value-Based Medicine

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103 Request Patient Case Management Services TRAINING GUIDE CURRENT VERSION V HEALTH ENDEAVORS 2016

104 HEALTH ENDEAVORS 2016

105 Health Endeavors CCM Consent Health Endeavors Clinic Contact HEALTH ENDEAVORS 2016

106 Mandatory Mandatory Mandatory Mandatory HEALTH ENDEAVORS 2016

107 Mandatory only if patient has an authorized delegate for care Mandatory only if patient has an authorized delegate for care Mandatory only if patient has an authorized delegate for care Mandatory only if patient has an authorized delegate for care Click Save (DO NOT CLICK Save and Close) HEALTH ENDEAVORS 2016

108 Request Patient Case Management Services TRAINING GUIDE NEW RELEASE DECEMBER, 2016 V HEALTH ENDEAVORS 2016

109 Updates Find Patient Add Patient Select Payor Type Select Program Type Coming Soon - Edit Patient launches patient portal - Myhe.com patient portal

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111 Health Endeavors CCM Consent Health Endeavors Clinic Contact HEALTH ENDEAVORS 2016

112 Mandatory Mandatory Mandatory Mandatory HEALTH ENDEAVORS 2016

113 Mandatory only if patient has an authorized delegate for care Mandatory only if patient has an authorized delegate for care Mandatory only if patient has an authorized delegate for care Mandatory only if patient has an authorized delegate for care Click Save (DO NOT CLICK Save and Close) HEALTH ENDEAVORS 2016

114 Contact Us Kris Gates, CEO 11/14/