9:15 10:30 am Chronic Care Management (CCM): Optimizing Practice Revenue and Improving Care SPEAKER Kenneth Giacobbo, DO Presenter Disclosure Information The following relationships exist related to this presentation: Kenneth Giacobbo, DO: No financial relationships to disclose. Off-Label/Investigational Discussion In accordance with pmicme policy, faculty have been asked to disclose discussion of unlabeled or unapproved use(s) of drugs or devices during the course of their presentations. CHRONIC CARE MANAGEMENT (CCM): OPTIMIZING PRACTICE REVENUE AND IMPROVING CARE DR. KENNETH GIACOBBO HOMEVISIT PHYSICIANS Chronic Care Management is an advancement in the way health care professionals can engage in and effectively manage the complex care of elderly patients while also involving their care givers, families and clinical partners. This unique collaboration will work to improve the quality of our patients lives while easing the burden on caregivers and families as they navigate both the aging process and the health care system. Dr. Kenneth Giacobbo Objectives o Understand the value of the new chronic care management (CCM) program and how best to ensure compliance according to CMS guidelines o Acquire important tools for decreasing gaps in care while managing risks, reducing costs and improving patient outcomes Caring for the Aging Population Brick and Mortar: Internal Medicine and Hospice and Palliative Care Certified Office based practice for 15 years 10,000 patients Rehab, Imaging, and Ancillary Services under one roof Declining Reimbursements (see more patients, spending less time with patients) Transitioned in 2007 o Learn how to seamlessly integrate these patient-centered solutions within your practice workflow and EHR so as to unify communication and care coordination for patients, family members, outside providers and care staff
Caring for the Aging Population HomeVisit Physicians: Started in 2007 to make care more accessible to the homebound population 1,800 patients, seen in the home, assisted living and IL Still at the center of care coordination, recognize the lack of care in the gaps between visits Started CCM Services in June of 2015 to improve the quality of care and increase practice revenue 45 MILLION OLDER ADULTS 85 M I L L I O N BY 2050 36 M I LL I O N ELIGIBLE CCM PATIENTS 916,26 4 PHYSICIANS 300 EHR SOLUTIONS 1,000 s ANCILLARY PROVIDERS VNA Patient Care is Fragmented PCP HHA Specialists Patient Family Therapies CCM = Comprehensive, Coordinated Care Being the Center of Care Coordination Requires Time VNA HHA PCP Patient Therapies Family Specialists Roughly 12 Million Hours Annually Spent on Care Coordination CCM Empowers Physicians to provide cohesive, patientcentered care
Chronic Care Management January 2015 The new Medicare Physician Fee Schedule, effective January 1, 2015, provided a billing code (CPT 99490) for 20 minutes of non face-to-face time spent managing 2 or more chronic care conditions. Up to $42/month per patient Who Can Bill? The CCM code can only be billed by: A physician An advanced practice registered nurse A clinical nurse specialist A physician assistant Only one provider can bill per patient per month (yes, it s a land grab) Exclusions CCM cannot be billed with the following CPT codes in a given month: Transitional Care Management (99495 or 99496) Home Healthcare Supervision/Care Plan oversight (G0181) Hospice Care Plan Oversight (G9182) Certain ESRD Services (90951-90970) Whose time counts? Licensed Clinical Staff Members Including: Physicians APRNs PAs RNs LPNs LSCSWs Pharmacists CMAs 2+ 2 or more chronic conditions CCM Core Requirements EHR 24/7 Successive Appointments Utilize 24/7 access certified to EHR Care Team Written Consent Monthly Care Plan 20 20 minutes of non face-to-face care management 2+ 2 or more chronic conditions Definition: 2 chronic continuous or episodic health conditions that are expected to last at least 12 months, or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. Examples: CHF, COPD, Diabetes, CAD, Hypertension, Alzheimer s Disease, Depression etc.
EHR Utilize certified EHR Certified CCM Technology: According to the CMS guidelines for CCM, the use of a version of certified EHR that is acceptable under the EHR Incentive Programs. Refer to the link: www.cms.gov/regulations-andguidance/legislation/ehrincentiveprogra ms on the CMS website 24/7 24/7 access to Care Team Patients have: Access to care team 24 hours a day, 7 days a week, including telephone access and other nonface-to-face means of communication. Care Team Has: Access to the patient s care plan 24 hours a day, 7 days a week. Successive Appointments Patients have: The ability to get successive, routine appointments with their designated primary care provider or member of their care team. 20 20 minutes of non face-to-face care management Contact-Based Care: How to Reach the 20 Minute Requirement Must be contact-initiated This could be patient-doctor, patient-nurse, doctor-doctor, pharmacy-doctor, lab-doctor, or other contact regarding the patient or by the patient via phone or electronic communication. General planning time or care coordination does not count towards the 20 minute requirement unless it is initiated based on a contact and/or results in a patient or patientrelated contact. Monthly Care Plan Create a patient-centered care plan based on a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment, and an inventory of resources (a comprehensive plan of care for all health issues); Provide the patient with a written or electronic copy of the care plan and document its provision in the medical record; Ensure the care plan is available electronically at all times to anyone within the practice providing the CCM service; Share the care plan electronically outside the practice as appropriate. Implementing CCM in Your Practice Empower patients to actively manage their chronic conditions
Step 1: Select a solution to support a CCM rollout Software as a service Third party clinical providers Leverage your existing EHR Step 2: Identify your patients Identify the top conditions and run a report Load the patients, or flag them in the system you select to manage CCM Step 3: Designate Office Personnel Designate point of contact for patients enrolled in CCM Designate office CCM lead to educate staff on CCM Identify team to educate patients about CCM Identify team member billing for CCM Step 4: Design a CCM Process Talking points and create consent form Top functions within the office that you will track time on Create rules for the development of a monthly care plan Tracking patient transitions (Hospital stays/home health) Step 4: Design a CCM Process Talking points and create consent form Top functions within the office that you will track time on Create rules for the development of a monthly care plan Tracking patient transitions (Hospital stays/home health) Step 5: Launch Patient CCM Consent forms Monitor time tracking Measure staff compliance Track successful CCM moments to share with the staff Develop comprehensive care plans and distribute to your patient population
Step 5: Launch Patient CCM Consent forms Monitor time tracking Measure staff compliance Track successful CCM moments to share with the staff Development comprehensive care plans and distribute to your patient population Meet Mrs. Smith 8 Minutes 7 Minutes Call with Patient and POA on Care Coordination with the Medication Reconciliation and Specialist Education 10 Minutes 5 Minutes Review and approval of VNA Physical Therapy Referral orders with communication with VNA staff 30 Minutes in January Value to my Practice Better Patient Care What to look for in a CCM Solution Higher level of communication with our patients and their families Leveraged CCM to improve how our offices functions Identified incorrect medication and patient information in our system Increased practice revenue It s a slow process but a positive step to better care HIPAA Compliant o Secure o Safe Time Tracking log o Track non faceto-face time per patient o View monthly graph Analytics + Reports o Run reports quickly and easily Comprehensive Care Plan Creation o Ensure compliance o Educate patients 24/7 Patient Access o Provide access to care plans o Provide support The Future of CCM More patient and family engagement Higher reimbursement & CCM is leveraged as a trigger for reimbursement Connectivity within the continuum of care enhanced Provide Better Care For More Positive Outcomes References American College of Physicians. (2015). Chronic care management toolkit: What practices need to do to implement and bill CCM codes. Retrieved from https://www.acponline.org/running_practice/payment_coding/medicare/chronic_care_manage ment_toolkit.pdf Bendix, Jeffrey. (2014). Getting paid for chronic care. Medical Economics. Retrieved from http://medicaleconomics.modernmedicine.com/medical-economics/news/getting-paid-chroniccare?page=full Center for Medicare & Medicaid Services (2015). Chronic care management services fact sheet (DHHS ICN 909188). Retrieved from https://www.cms.gov/outreach-and- Education/Medicare-Learning-Network- MLN/MLNProducts/Downloads/ChronicCareManagement.pdf United States Census Bureau. (May 2014). An aging nation: The older population in the United States. Retrieved from https://www.census.gov/prod/2014pubs/p25-1140.pdf