Minnesota Department of Health (MDH) Health Care Homes (HCH) HCH Recertification Training. Reviewed: 03/22/18

Transcription

1 Minnesota Department of Health (MDH) Health Care Homes (HCH) HCH Recertification Training Reviewed: 03/22/18 1

2 Learning Objectives 1. Describe the Health Care Homes legislative criteria as required at recertification. 2. Review the progression of recertification as it addresses improvement to population health. 3. Describe the requirements for statewide quality improvement reporting and measurement for certified HCH clinics. 2

3 Health Reform in Minnesota Minnesota s 2008 health reform law seeks to fulfill the promise of the Institute for Healthcare Improvement s Triple Aim Improve the health of the population Improve the patient/consumer experience Improve the affordability of health care Institute of Medicine s Triple Aim 3

4 Minnesota Health Reform The health reform law resulted in the following MDH initiatives Health Care Homes (HCH) All Payer Claims Database (MN APCD) Statewide Health Improvement Partnership (SHIP) Statewide Quality Reporting and Measurement System (SQRMS) 4

5 The HCH Program The HCH Program is one of the centerpieces of Minnesota's health reform initiative. Through redesign of care delivery and meaningful engagement of patients, HCH Clinics are transforming care and lives - for millions of Minnesotans. The name "Health Care Homes" acknowledges a shift from a purely medical model of health care to a model which links primary care with wellness, prevention, self-management and community services. 5

6 Goals of the HCH Program Continue to build strong primary care foundation ensuring all Minnesotans have the opportunity to receive team-based, coordinated, patientcentered care. Increase care coordination and collaboration between primary care and community resources to facilitate the broader goals of improving population health and health equity. Improve the quality, experience, and value of care. 6

7 HCH Certification Updates Certified HCH Clinics Applicants are from all over the state. Variety of practice types such as solo, rural, urban, independent, community, FQHC and large organizations. All types of primary care providers are certified: family medicine, pediatrics, internal medicine, OB/GYN and geriatrics. 7

8 The Patient- and Family-Centered Health Care Home 8

9 Recertification Questions: Clinician and/or clinic changes As HCH model is implemented in new clinic sites (referred to as spread ) the new clinicians are certified. Find the Add Clinic Guide on the MDH HCH website. When a previously certified clinician leaves a clinic and goes to work at a non-certified clinic, the new clinic and clinician/s apply for their certification. The previous clinic employer identifies an end date for that clinician in the HCH online portal. Find the Amend Clinicians Guide on the MDH HCH website. 9

10 Recertification Timeline page2 Goal: Maintain relationship, provide ongoing technical assistance and facilitate forward movement of implementation of standards. Initial Certification Recertification: 3 years from initial certification date (HCH portal will generate a 180 and 90 day notice) Subsequent years: Repeat process of every 3 year recertification The Organization submits letter of intent, application/s, and assessment containing the odd numbered standards 1-9 only. The MDH Nurse Planner will then schedule a Health Care Home site visit evaluating the implementation of the odd numbered standards, 1-9 only. The Organization submits letter of intent, application/s, and assessment containing all standards. The MDH Nurse Planner schedules a team meeting to review all standards in the following manner; Changes with any odd numbered standards 1 9 Review of the even numbered standards Review of standard 11 Review any variances The Organization submits letter of intent, application/s, and assessment containing all standards. The MDH Nurse Planner schedules a team meeting to review all standards. Review any changes in standards Review any variances Analyze benchmarks *MDH Nurse Planner will contact the certified Health Care Home organization and offer optional check-ins during the 3-year certification cycle. 10

11 Progression Over Time HCH clinics are recertified every three years in a Team Meeting format. Recertification ensures the progression in the HCH model implementation over time. Clinics have the option of scheduling a technical assistance/coaching check-in visit or phone call with their designated nurse planner. The certifying HCH clinic/s meets all requirements or applies for a variance. A variance may be granted for good cause or when failure to grant a variance would result in hardship. 11

12 Recertification Requirements Continue to meet all initial certification requirements (.0040 Subparts 1,3,5,7,9). Submit documentation by exception. Updates to specific subparts are required: 1A; 5A; 8; 9A; 9D; 10A; 11 Address any recommendations and/or variances, if applicable. 12

13 MDH HCH website Portal link 13

14 Log-in to the MDH HCH Portal 14

15 Recertification Steps for the Applicant Guides & Tools Step 1: Complete LOI Step 2: Verify Clinic/s Step 3: Update Assessments (Odd number) Step 4: Update Assessments (Even number) Step 5: Team Visit Step 6: MDH Notification Optional Step: Variance and Appeals 15

16 Guides & Tools Preparation and guidance 16

17 Step 1: Letter of Intent I. Applicant Intent II. Applicant Demographic Information Organization/clinic name, address, applicant clinician(s) information III. HCH Information Yes/ No questions regarding health care home policies and procedures IV. Additional Information V. Contact Information 17

18 Step 2: Verify Clinic Update Application for each Clinic/Clinicians. I. Applicant Demographic Info Organization/ clinic name, address, applicant clinician(s) information II. Additional Clinician Info Providers and services available to clinic, hours working on HCH III. Clinic s Patient Profile Age, race, gender, payer mix, language, patient characteristics IV. Representations and Signature of Authorized Person 18

19 Steps 3 & Steps 4 Recertification Assessments Recertification Assessment Tool Online submission of individual subparts 19

20 Recertification Assessment Tool Documentation and Data Sources At initial certification the clinic meets the ODD numbered subparts (1,3,5,7,9). There are ten documents to submit. Progression is ensured through the addition of the EVEN numbered subparts (2,4,6,8,10). Documentation examples include: written policies, protocols and procedures workflows guidelines forms, flow sheets EMR and registry screen shots patient education materials, prepared resources, pamphlets meeting minutes with dates and member roles de-identified patient medical records PDSA cycles 20

21 Submission of individual Subparts The hyperlinks to Rule Intent and Rule Language correlate with the Certification Assessment Tool. The clinic may note see attachment if all the information is summarized in the document. The clinic s brief narrative describes the work for the subparts where a document is not attached. Statements should be concise and succinct, initial certification provides baseline information. 21

22 Step 3: Update Assessments Complete Odd Numbered Standards. The recertification self-assessment is used to determine if the applicant meets the documentation requirements for HCH recertification and is ready for a team visit. Applicants submit their HCH Assessment online at least three weeks prior to their recertification team visit. Site evaluators will review the clinics submitted assessment prior to the team visit. 22

23 Eligibility Requirements A - Clinic organizational Structure *required document (*consider the position of the patient) B - Board Certification/Licensure: HCH Structure *required document (*this is met in the contents of the LOI) 23

24 Access and Communication Standard A 1,2 - Services to all patients with chronic & complex conditions interested in participation in care coordination services. *required document B 1,2 a,b,c,d & 3 a,b - Access to patient information. *required document C - Collect and apply cultural and language information D - The patient s preferred method of communication E - Inform patients of access to specialty resources F - Ensure compliance with privacy and security 24

25 Access and Communication Standard A 1,2 The applicant establishes a process to systematically screen patients to identify patients who would benefit from care coordination services based on the patient s medical and non-medical complexity. A population screening Defines patient risk level Trigger to identify as a patient receiving CC services Policy/protocol outlines the who does what and how of identifying patients for care coordination. 25

26 Access and Communication Standard B 1,2 a,b,c,d & 3 a,b Aa system to support continuous access during and after regular clinic hours for patient to communicate with the HCH team and the team knows the patient s preferred communication method. 1) Patients are informed that they have continuous access 2) the designated clinic staff has continuous access to medical record information: (a) contact information, PCP name and contact information, patient identified as receiving CC services. (b) racial or ethnic background, primary language and preferred means of communication (c) Consents and restrictions for releasing medical information (d) the patient's diagnoses, allergies, medications related to chronic and complex conditions, and whether a care plan has been created for the patient 3) appointment scheduling is appropriate based on: (a) acuity (b) access to avoid unnecessary ER visit or hospitalization 26

27 Access and Communication Standard C Language, ethnic and racial background supports the provision of relevant care, that is of value to the patient and supports a culturally appropriate care plan. Process to document the information Staff is trained Plan to access interpreters as appropriate 27

28 Access and Communication Standard D The clinic asks the patient and their family about their preferred method of communication. This information is accessible to the HCH clinic team. 28

29 Access and Communication Standard E The patient may choose a specialty care resource without regard to whether a specialist is a member of the same provider group or network as the patient's health care home, and that the patient is then responsible for determining whether specialty care resources are covered by the patient's insurance. 29

30 Access and Communication Standard F The applicant has privacy and security measures to comply with the requirements of the Health Insurance Portability and Accountability Act, Code of Federal Regulations, title 45, parts to , and the Minnesota Government Data Practices Act, Minnesota Statutes, chapter 13 30

31 Registry Standard 3A - Searchable registry for systematic population review *required document The applicant uses a registry and process to guide the management of health care services, provide appropriate follow-up and identify any gaps in care for clinic populations. 3B 1,2 - Electronic registry data elements necessary to track care. (name, age, gender, contact information, and identification number) 31

32 Care Coordination Standard 5A 1,2,3 - Requirements for care coordination team 5B - Use of health care team, designation of personal clinician, & patient is informed *required document 5C - Routine face-to-face discussion between personal clinician & care coordinator 5D - Dedicated time for care coordinator *required document 5E 1,2,3,4,5,6 - Care Coordination processes & documentation 32

33 Care Coordination Standard 5A 1,2,3 HCH team relationships are central to the HCH. The PCP, CC and patient relationships support effective information sharing, goal setting, care coordination, care planning and follow-up support. The patient and the care team set goals and identify resources to achieve goals. The PCP and CC ensure continuity of care. The patient and care team identify method of contact with the care team and community services. 33

34 Care Coordination Standard 5B Health care team, designation of PCP, and patient is informed *required document To assure continuity of care, each patient has a designated primary care provider. Patients receiving care coordination services also have a designated care coordinator. The health care home teams provide and coordinate the patient s care, including communication and collaboration with specialists. Process for selecting PCP PCP and CC (if receiving CC services) are identified in the EMR 34

35 Care Coordination Standard 5C Routine face-to-face discussion between personal clinician and care coordinator Direct communication in which routine, face-to-face discussions take place between the PCP and the care coordinator. Definition: Subp. 15. Direct communication. "Direct communication" means an exchange of information through the use of telephone, electronic mail, video conferencing, or face-to-face contact without the use of an intermediary. For purposes of this definition, an interpreter is not an intermediary. 35

36 Care Coordination Standard *required document 5D Dedicated time for care coordinator Designated protected time is essential to performing care coordination functions and making improvements in population outcome measurements. Job description Job responsibilities Job training 36

37 Care Coordination Standard 5E Care coordination processes reflect a plan for communication between the team and the patient to assure continuity of care and services. 1. Referral tracking and follow up 2. Tests ordered, results tracked and timely notification to patients 3. Admissions to hospital or skilled nursing facilities are tracked 4. Timely discharge planning 5. Medication reconciliation and pharmacy communication 6. Links to external team members and care plans 37

38 Care Plan Standard 7A 1,2,3,4,5,6 - Care plan policies & procedures *required document 7B 1,2,3,4 & C - Care plan goals & action plans 38

39 Care Plan Standard 7A 1,2,3,4,5,6 Care Planning Policy/Procedure document *required document 1) actively engage and verify joint understanding of the care plan 2) engage all appropriate members of the health care team 3) incorporate pertinent elements of the assessment about the patient s health risks and chronic conditions 4) review, evaluate, and, if appropriate, amend the care plan, jointly with the patient, at specified intervals appropriate to manage health and measure progress toward goals 5) provide a copy of the care plan to the patient upon completion of creating or amending the plan 6) Use and document the use of evidence-based guidelines for medical services and procedures. 39

40 Care Plan Standard 7B 1,2,3,4 & C Care plan goals & action plans PCP and CC; preventive care; care of chronic conditions; management plan for exacerbations of chronic conditions; end of life planning; patient identified, patient centered goals and resources to achieve those goals. De-Identified Care Plans uploaded or available at the site visit for review by the MDH HCH Team- will review for the required elements, and SMART Goals. 40

41 Quality Improvement (QI) Standard 9A 1,2,3,4 - Establishes HCH quality team that reflects clinic structure *required document 9B - Quality team has a mechanism for communication & feedback *required document 9C - Quality team demonstrates ability to do quality measurement 9D 1,2,3,4 - Participation in the learning collaborative 9E - Team has mechanism for communication & feedback for information from Learning Collaborative 41

42 Quality Improvement Standard 9A 1,2,3,4 HCH quality team that reflects clinic structure *required document A patient- and family-centered health care home relies on patients and health care team members to provide input to the clinic s quality activities. Patient Partners two or more Personal Clinician Clinic administration or management Care Coordinator Submit six months of quality team meeting minutes 42

43 Quality Improvement Standard 9B Quality team has a mechanism for communication & feedback *required document The applicant follows procedures to share their work and elicit feedback from HCH team members staff regarding quality improvement. Process How are staff informed of QI How are patients informed of QI 43

44 Quality Improvement Standard 9C Quality team demonstrates ability to measure, analyze, and track changes in at least one quality indicator selected by the applicant based upon the opportunity for improvement. Patient advisory involvement? What is the objective? What are the methods How will you measure What was the outcome? Next Steps? A PDSA process 44

45 Quality Improvement Standard 9D 1,2,3,4 Participation in the learning collaborative. The MDH HCH Learning Collaborative provides a supportive learning environment for the clinic. Participation through representatives that reflect the structure of the clinic is encouraged: (1) one or more clinicians who deliver services in the HCH (2) one or more care coordinators (3) one or more administration/management participants (4) two or more patient representatives *Documentation of staff attending, dates, sessions. 45

46 Quality Improvement Standard 9E Team has mechanism for communication & feedback for information from Learning Collaborative *required document The applicant has a process for sharing information and eliciting feedback as a result of participation in the MDH HCH Learning Collaborative. *This process could be addressed in 9B 46

47 Step 4: Update Assessments Complete Even Numbered Standards. The recertification self-assessment is used to determine if the applicant meets the documentation requirements for HCH recertification and is ready for a team visit. Applicants submit their HCH Assessment online at least three weeks prior to their recertification team visit. Site evaluators will review the clinics submitted assessment prior to the team visit. 47

48 Recertification Subparts to reflect progress Subpart 2 Patient Activation Subpart 4 Registries to Track Gaps in Care Subpart 6 Shared Decision Making, Community Partnerships, Teams working to the full extent of licensure, Transitions in Care Subpart 8 External Care Plans Subpart 10 Quality Measurement and Triple Aim Quality Plan 48

49 Access and Communication Standard.0040 Subpart 2 Patient Participation Submit strategies used to encourage patients to take an active role in managing their care. Describe the clinic s progress in one area: Patient s readiness for change Literacy level Barriers to learning 49

50 .0040 Subpart 2 Patient Participation Examples: Clinic Level Process: Measurement of patient and family centered care: PCMH-A (questions 9-11) Family voices The Institute for patient & family centered care Individual Patient Process: Teach-Back Method Ask Me 3 Patient Activation Measure (PAM) Literacy Assessment/Questionnaire 50

51 .0040 Subpart 4 Registries & Tracking Gaps in Care Documented process with identified staff time for: Pre-visit planning Call reminders for preventive care or procedures Follow-up appointments for chronic conditions Guidelines to identify patients with gaps in services Evidence that the registry is actively worked by the care team Internal audit process Job performance review Blinded copies of completed work tools Work assignments 51

52 Examples:.0040 Subpart 6A Shared Decision-Making Workflows to solicit patient participation & shared decision-making Policies patient and family-centered principles Job descriptions Education programs Tools: Patient Activation Measure (PAM), Ottawa Shared Decision Making tools, questionnaires or other tools Measurement of patient /family centered care Patient stories/chart documentation 52

53 .0040 Subpart 6B Community Partnerships Demonstration of on-going partnership with at least one community resource. Meeting Minutes Communication or education plan Formal referral agreements Work plan Examples of community resources Waiver or Senior services Local public health Home Health Assisted living Schools Behavioral Health 53

54 .0040 Subpart 6C Care Team Practices to the top of licensure Clinicians & team members working at the top of their education, licensure, and training. Job descriptions/responsibilities Workflows, swim lanes QI project related to workflow or team responsibilities 54

55 .0040 Subpart 6D Planning for Transitions in Care Anticipatory planning care transitions: Pediatric to adult care Transition to assisted living, skilled nursing or memory care facility Transition to temporary rehabilitation Transition to palliative care or hospice 55

56 .0040 Subpart 8 External Care Plans Identify patients with care plans who also have external care plans. Process used to create a comprehensive care plan which adds relevant information from the external care plan. Examples: wound care, falls prevention, behavioral health, asthma action plan. Submit evidence/documentation demonstrating integration of external care plans. 56

57 .0040 Subpart 10 Quality Measures Examples of Triple Aim Indicators: Reduced duplication of services Hospital readmissions, ER usage Poly pharmacy Patient satisfaction surveys Immunization rates Advanced directives, physician orders for life sustaining treatment (POLST) Optimal care scores 57

58 .0040 Subpart 10 A Reporting & Quality Improvement1 Statewide Quality Reporting Patient level data: Pursuant to Minnesota Rules, chapter , and Minnesota Statutes, section 256B.0752, the applicant will submit health care homes data in the manner prescribed by the commissioner to fulfill evaluation requirements. To meet this requirement, the applicant will submit patient level data to MDH, in the manner prescribed by the commissioner. The applicant will submit data through the MDH contracted data collection vendor; the data collection vendor will provide de-identified patient-level data from the applicant to MDH for the purposes of evaluation. 58

59 .0040 Subpart 10 A Reporting & Quality Improvement2 Statewide Quality Reporting Please see the HCH Performance Measurement & Evaluation Data Submission webpage for current SQRMS measures. 59

60 .0040 Subpart 10 B Quality Improvement Planning The clinic demonstrates they have measured, analyzed, and tracked an indicator from each Triple Aim of health improvement: Improvement in patient health Quality of patient experience Cost effectiveness of services 60

61 Health Quality Care Homes Plan Document Recertification Quality Plan Document Standard 10B: At Recertification the HCH selects at least one quality indicator from each of the following categories below ( triple aim ) and measures, analyzes and tracks those indicators throughout the year. To meet this standard the HCH submits its annual quality plan and quality reports with data that has been measured, analyzed and tracked. The quality plan may include the quality measures that are submitted to the Statewide Quality Reporting System or may be based on other quality needs. Quality plans may be submitted in any form. The following is an example template of how the clinic might organize their quality plan. PDSA (Plan, Do, Study, Act) planning cycles also work well to meet this standard by demonstrating the quality work in the quality plan, or other structured QI methods. Quality Plan Quality Goals in Each Category. Data Collection Methods (Measures / Tools / Methods) Clinical improvement in patient health Action Plan (Timeline, responsible person, PDSA.) Patient Experience Cost Effectiveness 61

62 Quality Plan Document Example 62

63 HCH Benchmark Reporting 63

64 .0040 Subpart 11 A, B Shows internal improvement over time Reflects comparison of MN HCH certified clinics Follows established state or federal standards Uses best practices, outcome-based measures Assures accountability at recertification Reflects the framework for statewide quality improvement 64

65 HCH Benchmarks 65

66 Benchmarking Approach Internal and external benchmarking using a hierarchy approach: A performance (comparison) benchmark, and An internal improvement benchmark Benchmarks are established at the clinic level. Statewide averages are the aggregate of all the optimal patients eligible to be in the measure. Health Care Home averages are the aggregate of all the optimal patients eligible for the certified health care home. 66

67 Statewide and HCH Averages The statewide average is calculated by taking the total number of optimal patients in the state (numerator) divided by the total number of eligible patients in the state (denominator). The health care home average is calculated by taking the total number of optimal patients at the HCH clinic sites (numerator) divided by the total number of eligible patients at the HCH clinic sites (denominator). 67

68 Improvement Benchmark If a clinic s rate is less than the statewide average then MDH will review the relative percent change from the previous year. Factors to consider when reviewing the relative percent change from the previous year are: High improvement can be considered a 10 % change or greater from the previous year. Stable performance can be considered a change in performance between (-9.9% to 9.9%) from the previous year. Reduced performance can be considered a change greater than 10 % from the previous year. 68

69 Performance Benchmarks 69

70 Improvement Benchmark If a clinic s rate falls into the low performance range then MDH will review the change in performance from the previous year and work directly with the clinic to determine if an action plan and variance is needed to meet the standard. 70

71 Benchmarking - Baseline and Beyond One year following the initial HCH certification the benchmarking results serve as the baseline for the clinic. Three years following initial HCH certification benchmarking results are a major component of the recertification process. Benchmark results become the measure of clinical quality. 71

72 Access to MNCM Benchmarking Reports 72

73 Recertification Team Visit 73

74 Step 5: Team Visit The Team meeting is an opportunity for the clinic or organization to share their story of HCH progression. Applicants should include care team representation, care coordinator(s), leadership, and patient partners. Assesses the progression in HCH implementation within the care delivery model. Completed by trained reviewers from clinical staff, consumers and Minnesota State employees. Completed in a two hour team meeting format. 74

75 Preparing for Team Visit Planning will take place with your regional HCH Nurse Planner. Some common topics include: Culture change and care team development Successes and challenges New planned initiatives Required updates to subparts Review of previously unresolved recommendations and variances Review of quality improvement activities, committee structure changes, and data collection Review of SQRMS Benchmark report 75

76 Team meeting: Benchmark Reporting Review and discuss HCH benchmarking data at the team meeting. Based on results the certified clinic may: Submit a variance for superior outcomes and continued progress on standards if eligible, or Continue with present improvement plan, or Submit a variance with action plan for justifiable failure to show measureable improvement. 76

77 Application Process An automated MDH notifies the applicant that the recertification completion date is 90 days away. During this time period: Required letter of intent, application and self assessment have been submitted. Required documents have been submitted and reviewed. Team visit has been completed. 77

78 Step 6: MDH Notification MDH will notify the applicant of certification status. The report summarizes how the clinic is meeting each of the standards. Applicants meeting all of the standards are recertified. Celebrate! Payer notification to be completed by the applicant. 78

79 Variances and Recommendations 79

80 Optional Step: Variance and Appeals Options for unmet standards: Submit a request for a variance. Request support or technical assistance from MDH. Develop and submit a corrective action plan which is reviewed by MDH. File an appeal. The applicant has 30 days from the date of receiving a certification denial notice to appeal the decision. 80

81 Variance Criteria Subpart 1 At certification or recertification, the applicant may request a variance or the renewal of a variance from a requirement in parts to

82 Variance Types Minor variance may be granted to the HCH for good cause or when failure to grant a variance would result in hardship. It is identified that a minor element of the rule is not implemented. Experimental variance may be granted where a HCH offers an innovative replacement to meet the standard. Hardship Variance: A significant hardship that prevents implementation. 82

83 Variance Process Applicant submits a variance for an identified subpart within the HCH online portal. The Nurse Planner is available to support the applicant with this process. 83

84 Variance submission A variance may be submitted: During the application process After the site visit During remedial planning After an appeal 84

85 Variance Duration Subpart 2. Conditions and duration. The commissioner may impose conditions on the granting of a variance according to Minnesota Statutes, section The commissioner may limit the duration of a variance and may renew a variance. Variances are normally in place for one year or until resolved. Clinics may submit a request to extend a variance. 85

86 Recommendations Recommendations are observations made by the site visit evaluators reflecting opportunity for improvement. Recommendations are: Not prescriptive Addressed by the clinic as appropriate Reviewed at the following recertification to describe how they were addressed. 86

87 Reimbursement for Care Coordination Services 87

88 Care Coordination: Billing and Reimbursement Legislative Requirements for HCH Care Coordination Payment: [256B.073] DHS and MDH developed a system of per-person care coordination payments to certified HCHs Fees vary by thresholds of patient complexity Agencies consider feasibility of including non-medical complexity information Implemented for all public program enrollees by July 1, [62U.03] Covers SGIP, small group self-insured 88

89 Care Coordination Payment Guiding Principles HCHs provide population management. Every patient is part of the clinic s HCH. HCHs determine which patients will benefit from: care coordination and are eligible for reimbursement routine panel management (preventive care, appointment follow-up). Clinics implement key processes for successful care coordination billing. 89

90 Population Management Goal Clinics implement processes to identify patients from the entire clinic population who would benefit from care coordination services. New patients Current patients with health changes Established patients with chronic conditions. Patients who are identified and decline care coordination services. 90

91 Population Management What does your population look like? 91

92 Implement HCH Tier Tool 92

93 Complexity Tier Level Needed for Payment Patient s Tier Level (based on the count of major condition groups) Tier 0 (none) Tier 1 (1-3) Tier 2 (4-6) Tier 3 (7-9) Tier 4 (10 or more) Presence of either of the two supplemental complexity factors 93

94 Workflow Development: Tiering & Billing Determine who does what and when. Complete the Care Coordination Tier Assignment tool. The care team establishes a work flow for communication of the tier score. Key: Establish billing and accounting department workflows and communication processes. Establish payer contracting (see slide #98). Develop automated workflows within EMR. May begin with a manual process. Tier level is supported by documentation. 94

95 Coding Structure for Billing 95

96 Key Billing Process Steps 96

97 Key Denial Process Steps 97

98 Multi- Payer Communication Prior to Certification, identify payer networks supporting care coordination reimbursement. Work with payers to establish payment rates and method of claim submission and payment Tiering Methodology (Medicaid; private and commercial plans) PMPM Contract Arrangements CMS Medicare Care Coordination (chronic care management codes see slide #99-100) Identify payers where there may be a patient co-pay and determine a process. Address how to manage billing for uninsured. 98

99 New Medicare -CMS Chronic Care Management (CCM) Codes, January 2015 As of January 1, 2015, practices began submitting claims under new CCM codes. Payment/PhysicianFeeSched/index.html 99

100 CMS Chronic Care Management Codes Replaces Medicare: MAPCP, CPI and other PCMH demos. Practices need to meet standards similar to the HCH standards to submit claims. (see CMS requirements). Patient agreement to services is required. Service requirement of at least 20 minutes of clinical staff time directed by a physician or qualified health care professional per calendar month. Patient has two or more chronic conditions expected to last at least 12 months. Electronic health records requirement; specific requirement for an electronic care plan. A comprehensive care plan is established, implemented, revised and monitored. PCMH certification is not required. 100

101 Create Your Clinic s Roadmap Population Management in Health Care Homes Care Coordination Tiering Processes Billing Workflows Multi-payer Input 101

102 Evaluation Health Care Homes, Five Year Program Evaluation: Key findings from the University of Minnesota Evaluation 102

103 Health Care Homes A Business Case 103

104 Thank you! Visit the MDH HCH website: MDH HCH main phone number: questions to 104

105 HCH Nurse Planners Contact Information Bonnie LaPlante, MDH HCH Program Director Tina Peters Metro Area Kathleen Conboy Metro Area Joan Kindt Southern Region Danette Holznagel Northern Region