Chronic Care Management Lesa Schlatman RN, BSN Care Coordination Specialist ICAHN

Chronic Care Management Lesa Schlatman RN, BSN Care Coordination Specialist ICAHN

CHRONIC CARE MANAGEMENT: It can transform your quality of care Presented By: Lesa Schlatman RN, BSN Director Clinical Transformation - ICAHN 106

Learning Objectives: 107 Participants will learn what the regulatory requirements are for a compliant CCM program, and how to implement CCM within their RHC. Participants will learn how a successful CCM program can impact patient outcomes, quality initiatives, and overall system measures. Participants will learn what common hurdles exist for CCM implementation, and what options are available to overcome these barriers.

108 CCM: WHAT IS REQUIRED FOR COMPLIANCE

109 Eligible To Provide & Bill for CCM Services: Physicians Physician Assistants Nurse Practitioners Certified Nurse Midwives Certified Nurse Specialists (Not eligible in RHC/FQHC settings) Not Eligible To Bill for CCM Services: Licensed Clinical Social Workers Clinical Psychologist

REQUIREMENT: Initiating Patient Visit Face-to-face billable visit (E/M) PCP see patient within last 12 months Not required to discuss CCM services Required before commencing services 110

REQUIREMENT: Patient Consent for Enrollment Consent can be verbal or written Share required information: Explain services Patient costs: co-pay, etc. Only 1 PCP furnish per mos. Stop services any time Consult/share patient info with others Documentation to prove compliance 111

RECOMMENDATION: Utilize Patient Consent Form Better compliance less documentation Include more than required: Care co. provides majority of activity Majority services non-face-to-face PCP remains informed & consulted Ways patient info shared (email, fax, etc.) Signature lines: patient, care giver, witness 112

REQUIREMENT: 2 or More Chronic Conditions CMS Definition: Patient has two or more chronic conditions expected to last at least 12 months, or until the death of the patient, and place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline Chronic condition valid as long as meets definition There is not an all-inclusive list Chronic Conditions Warehouse: https://www.ccwdata.org/web/guest/home 113

REQUIREMENT: 24/7 Access to Care Patient access to care 24 hrs. day 7 days week No matter time of day or day of week Normal business hrs. = address all needs Outside normal business hrs. = address urgent needs Care team member available to consult if needed Patient plan of care & info accessible 114

REQUIREMENT: Comprehensive Care Plan Electronically created Patient involved in creating Copy inside EMR & copy to patient Available to others outside RHC/FQHC Remote access, fax, messaging Provide in timely manner Assess and reassess as needs change Minimum update is at least yearly 11 5

CARE PLAN: What Should it Contain? Address all identified needs: Physical, mental, cognitive, psychosocial, functional, & environmental Symptom management, interventions, & treatment plans Management chronic conditions main focus Current problem lists & health issues Inventory of resources & supports Patient identified goals & interventions Medication list with management & education 116

REQUIREMENT: Certified Electronic Medical Record (EMR) Meets current CMS standards: https://www.cms.gov/regulations-and- Guidance/Legislation/EHRIncentivePrograms/ Required to collect certain patient information: Demographics, problem list, medication list All allergies medication/non-medication 117

REQUIREMENT: Process for Transitions in Care Practice manages all patient care transitions to ensure: Communication/collaboration between providers/health care settings Timely sharing of patient s continuity of care document (CCD) Goal: Eliminate care gaps pt. info always available CCD: demographics / Lists: meds, problems, allergies / POC summary Timely = acceptable & reasonable for optimal treatment 118

REQUIREMENT: Successive Routine Appointments Patient always sees same assigned PCP Urgent/sick needs when possible Schedule several routine appointments at once Patient identified days Provide appointment cards Suggest call reminders 119

REQUIREMENT: Enhanced Communication Possibilities Patient/caregiver can communicate with PCP/Care team: By telephone & additional opportunities Asynchronous non-face-to-face consultation methods Patient portal, secure messaging, secure system, etc. Must be functioning if offer Patient may not use That is their choice: Document education on access/use done (include caregiver) Document response, refusal, & preferences instead Attempt set-up in person when possible 120

REQUIREMENT: 20 Minutes Non face-to-face Activities 20 minutes activities per CCM patient per month: Required to bill per calendar month (Jan, Feb, etc.) Clinical staff time counts only (no non-clinical or patient) Can count face-to-face time not counted elsewhere Activity directly related to chronic conditions Data review, education, consult w/providers, Tx changes, etc. Document/Track activities: start, stop, summary, changes 121

CHRONIC CARE MANAGEMENT: Program Specific Requirements to bill: Initiating Visit Patient consent for enrollment 2 or more chronic conditions 24/7 Access to care Patient Centered/Comprehensive Care Plan Certified EMR to record certain patient info Manage Care Transitions & share CCD Same PCP for all routine appointments Enhanced communication opportunity 20 min. non-face-to-face activities per month CMS Connect Care: Website resource for CCM https://www.cms.gov/about-cms/agency- Information/OMH/equity-initiatives/chroniccare-management.html Reimbursement: 99490 Chronic Care Management (original code) Approx. $42 per patient per month Commercial Ins. - Verify use with insurance G0511 General Care Management (new 2018 code) Approx. $63 per patient per month RHC / FQHC must use to bill Medicare Bill 1X Per Service period (1 cal. mos.-jan, Feb, etc.) Co-pays and deductibles apply Chronic Conditions Warehouse: Lookup for all identified chronic conditions https://www.ccwdata.org/web/guest/home 122

123 IMPLEMENTING CCM KEY STEPS & PROCESSESS

PREPARE ASSESS - BUILD 124 Prepare Your Process Assess & Identify Build Action Plan Determine: What You Have vs. What You Need

A Chronic Care Management program is not run by one person Teamwork = Success

From beginning involve everyone: Avoid Few Making Decisions for Many All Clinic staff All Providers Hospital Staff Administration Use We approach: We have or need How are We 126

Prepare Your Process Identify Care Team Assemble: Outline roles Outline expectations We CCM education Build Agenda: Meetings - timelines How communicate Approval process Develop Program GOALS 127

Develop Assessment Checklist(s) List CCM Required Elements: Process available to cover No process identify options Potential concerns Equipment/resource needs Staffing needs Education needs

Prepare Your Process CCM Program Already Implemented Review Team Structure: Included everyone We? Address team issues Restart - follow steps Develop Program & Team GOALS 129

Assess & Identify Assess: Current processes/workflows Staff availability/workloads Equipment/resources available Complete checklist(s) to Identify: What s in place/available What s lacking/needed Group decision items Implementation concerns 130

Assess & Identify CCM Already Implemented Assess: Processes - workflows Staff support - participation Identify Issues: Hurdles barriers Workflow inefficiencies Communication/collaboration No or slow growth 131

Build Action Plan Care team review assessment: Prioritize to do items Discuss concerns & solutions Identify options using Adjustable tool to track progress Target completion dates Review process - meetings Policy & procedure development

Completion Worksheets Required elements key topics All-inclusive task list Tools tracking - forms Equipment services Communication - education Assign worksheet Bring to review meetings

Build Action Plan Key Topics to Consider: Develop consent form Referral process Billing process Sliding fee scale or similar Speaking with patients: Educating staff Difficult topics (co-pays) Motivational scripting Phone interactions 134

What Impact can CCM have? 135

CCM IMPACT SATISFACTION COST OF CARE QUALITY MEASURES Happier with Care Improved Self-Care Abilities Provider-Patient Relations Provider - Staff Satisfaction Reduce PMPM rates Reduce Unnecessary Testing & Treatments Control Downstream Spend Reduce Readmit/ER Rates Improved Survey Scores Impact Compliance Rates

SEE THE PATIENT IMPACT EDUCATION LEVELS INCREASE SELF CARE ABILITIES IMPROVE IMPROVED COMPLIANCE HELP DRIVE CARE FEEL EMPOWERED HELP WHEN NEED IT FEEL IN CONTROL RECEIVES EXTRA ATTENTION FEELS LESS NEEDY FEEL HAVE A VOICE THEY MATTER SATISFACTION LEVELS RISE HAPPIER = HEALTHIER SHARE SATISFACTION IMPROVE MARKET SHARE 137

WHAT IS THE COLLECTIVE IMPACT? 138 IMPROVED PATIENT: EDUCATION LEVELS EDUCATION RETENTION COMPLIANCE TO PLAN OF CARE ABILITY FOR SELF CARE QUALITY OF HEALTH SUCCESS AT HOME AFTER D/C READMISSION/ER VISITS SATISFACTION WITH CARE, STAFF, HOSPITAL FOLLOW UP WITH PCP IMPROVED HEALTHCARE SYSTEM: SATISFACTION SCORES READMISSION RATES ER UTILIZATION RATES HCAHPS/SURVEY RESULTS PMPM RATES TREATMENT ERRORS & UNNECESSARY TESTS QUALITY OUTCOMES COMMUNICATION/COLLABORATION CARE TRANSITION PROCESSES POPULATION HEALTH EFFORTS

WHY DO NEGATIVE PATIENT OUTCOMES OCCUR? THE PATIENT DID NOT HAVE: WHAT THEY NEEDED WHEN THEY NEEDED IT 139

Common Care Gaps for Negative Outcomes 140 CARE TRANSITIONS DISCHARGE PROCESS & ORDERS NEW ORDERS, TESTING, TREATMENTS NEW PATIENT DIAGNOSIS EDUCATION & LEARNING SESSIONS FUTURE SCHEDULED ITEMS COMMUNICATION & COLLABORATION BETWEEN POINTS OF CARE PATIENT SELF CARE MED. ADMINISTRATION APPOINTMENT ADHERENCE ORDERS OUTSIDE OF HEALTHCARE SYSTEM PREVENTATIVE TESTING ROUTINE LABS, X-RAYS, TESTS REFERRALS TO SPECIALISTS INITIATION OF NEW SERVICES FOLLOW UP PROCESSES

AVOID CARE GAPS WITH CCM PATIENT EDUCATION: Disease process Self-care at home Early signs & symptoms Medications & why take Assess understanding & reteach EARLY INTERVENTIONS: Assess during frequent calls Post discharge/er visits Identify new needs early Avoid exacerbations Resource for help 24/7 141

142 Solutions to Avoid Common Mistakes & Hurdles

Lack Of Teamwork & 143 Accountability Require participation Everyone has a voice Identify consequences Group participation builds buy in & accountability

Team Lacks Direction VS. Hike the ball 25 hike ball to quarterback Front line blocks 33 & 57 block rushers to left Quarterback looks around Quarterback run left behind blockers Someone run down field 42 go left & 61 go right down field Pass ball to open player Quarterback pass to 42 or 61 144

Not everyone educated Poor education questions still Staff unsure of roles Tools not identified can t locate Resources unavailable Unsure of referral process Policy & procedure not in place Standard process not outlined 145

Diluted Care Coordinator Positions Make 100% devoted to CCM Avoid using to fill holes Realize down time is false Educate staff on above Avoid burn out 146

Wrong Mindsets Are we required to do it? Are we being measured on it? Does it bring us revenue? Our patients won t want that! Patients will not pay the co-pay! 147

The Right Mentality Not required but we should WANT to! Program impacts items we ARE measured on Revenue is also MONEY SAVED Patients Right to CHOOSE Patient s give CONSENT - not forced 148

PATIENTS WHO STRUGGLE TO PAY Utilize Sliding Fee Program or Similar: Adjusts based on income Every patient has access not just CCM Policy with guidelines in place Post in the patient area service offered Current poverty guidelines & application Co-pay/deductible don t waive or write off 149

Wrong Enrollment Process COLD CALLING: Patient turn off sales pitch MEDICARE PATIENT LIST: Inefficient extra work Not everyone appropriate CARE COORDINATOR ONLY: Growth slow missed opportunities ONLY TARGET ONE SOURCE: Growth limited - optimal enrollees missed 150

BUILDING YOUR CCM PROGRAM Primary Referral Sources Hospital Staff Case Mgr.- ED - Inpatient Staff Frequent Fliers - Readmits Staff Identifies Referral with Discharges Outline Your Process Standard Referral Process Provide Education Communication/Collaboration Identify Tools & Resources CCM Clinical Staff & Providers High Needs Patients Staff Identifies Discuss During Visit Review Schedule Daily 151 AWV Provider/Staff Offer to Patient Part of Preventative Plan Care Co. Completes Process

Poor Patient Knowledge of Program Not aware available or what it is: Posters in clinic & hospital Education sessions for public Advertise - mailings Staff discuss during office visits 152

STAFF & PROVIDER SUPPORT I am too busy mentality Do not recognize value Not required low priority Partnership mentality lacking Provide new education Administration involved Will actually create more free time Share potential impacts staff, clinic Share individual patient stories Use data to prove value 153

MONITORING DATA FOR CCM 154 COLLECT TANGIBLE & MEASURABLE DATA FACTUAL WAY TO SHOW IMPACT QUANTIFIES NEED FOR PROGRAM SHOWS ROI NOT JUST BILLABLE SERVICE BUILDS SUPPORT & PARTICIPATION FROM OTHERS

No Process to Share Success Share outside care team: Admin. team All clinic staff Board - governing bodies Community agencies - partners Why do this? Positive outcomes motivate others Offer help, join, support Shows care team hard work pays Show sustainability of programs 155

AVOIDING CCM CLAIM ERRORS ALL 3 DATES MUST MATCH 156 10 15 17 10 15 17 10 15 17 KEY POINTS: Do not use CG modifier Wrong dates overlapping dates with other service (TCM) Do no bill along with code

157 WHAT TO DO NEXT ACTION ITEMS & COLLABORATION

Action Items Assemble appropriate staff members Discuss information from today Compare current process to options shared Identify new needs or adjustments Outline plan to incorporate new practices Assign work to team members Develop goals as a team 158

159 STAY PERSISTANT YOUR PATIENTS WILL THANK YOU

References & Resources: 160 https://www.ncbi.nlm.nih.gov/books/nbk44012/ https://www.ahrq.gov/professionals/prevention-chroniccare/improve/coordination/atlas2014/chapter2.html http://familiesusa.org/sites/default/files/product_documents/care-coordination.pdf https://www.cms.gov/ https://www.cms.gov/about-cms/agency-information/omh/equityinitiatives/ccm/patient-resources.html https://www.cms.gov/outreach-and-education/medicare-learning-network- MLN/MLNProducts/Downloads/ChronicCareManagement.pdf www.cms.gov/medicare/medicare-fee-for-service- Payment/FQHCPPS/Downloads/FQHC-RHC-FAQs.pdf

QUESTIONS? LESA SCHLATMAN RN, BSN DIRECTOR OF CLINICAL TRANSFORMATION ICAHN PRINCETON, Il. 815-875-2999 I lschlatman@icahn.org 161