Reducing Clinician Burnout in Implementing Chronic Care Management

Reducing Clinician Burnout in Implementing Chronic Care Management

Learning Objectives Describe the benefits of Chronic Care Management (CCM) for patients and practices; Create a high-level workflow for CCM; Understand the barriers to CCM and strategies to overcome them; and Identify at least one process change to reduce clinician burden

Agenda Chronic Care Management (CCM) Overview Patient Benefits of CCM Services Practice Benefits of CCM Services Three Different CCM Approaches Utilizing Existing Practice Resources Outsourcing via Technology Pharmacy Partnering

CCM Overview and Benefits

Why CCM? CMS data shows two-thirds of Medicare beneficiaries have chronic conditions Chronic conditions are costly CCM contributes to better outcomes and higher patient satisfaction CCM helps patients better manage their care and focus on health and quality of life goals

CCM Description Chronic Care Management (CCM) services By: a physician or non-physician practitioners and their clinical staff For: patients with multiple (two or more) chronic conditions How often: 20 minutes or more per calendar month Separate billing codes established to provide payment for additional time and resources spent to provide between-appointment help patients need to stay on track with their care plans

Who Qualifies for CCM? Patients must have: Two or more chronic conditions expected to last at least 12 months, or until the death of the patient Examples include Alzheimer s Disease and related dementia, arthritis, asthma, cancer, cardiovascular disease, depression, diabetes, hypertension, obesity Chronic conditions place patients at significant risk Risk includes death, acute exacerbation or decompensation, or functional decline Establishment or revision of comprehensive care plan

Who Qualifies for CCM? Medicare Beneficiaries: All Part B recipients are covered Part B deductible and coinsurance apply Patients may also pay a monthly fee Inform patient before they agree to CCM services that a copay is required Informed consent can be verbal or written Collect copay at the time the CCM service is being performed to increase copay collection rate

CCM Service Line Target patients Use postcards or letters to inform them of service Have care team call and explain, obtaining consent Create, revise, or monitor care plan Work with patients on their plan Educate, motivate, check-in Repeat

CCM Service Line Target patients Educate, motivate, check-in Use postcards or letters to inform them of service Work with patients on their plan Have care team call and explain, obtaining consent

CCM Service Line Summary of CCM services: At least 20 minutes per month of CCM services Personalized care plan based on individual needs Coordinated care between doctor, pharmacy, specialists, testing centers, hospitals, and others Phone check-ins between visits 24/7 emergency access to a health care professional

Comprehensive Care Plans Care plan should include: A systematic assessment of the patient s medical, functional, and psychosocial needs System-based approaches to ensure timely receipt of all recommended preventive care services Medication reconciliation with review of adherence and potential interactions Oversight of beneficiary self-management of medications Care plan should be patient-centered and should be based on an environmental assessment of the patient s needs and available resources and support

Comprehensive Care Plan Elements Typically includes, but is not limited to: Problem list Expected outcome and prognosis Measurable treatment goals Symptom management Planned interventions and identification of the individuals responsible for each intervention Medication management Community/social services ordered A description of how services of agencies and specialists outside the practice will be directed/coordinated Schedule for periodic review and, when applicable, revision of the care plan

Asking for CCM Copay Use effective communication and language Ex: It is our payment policy to collect the appropriate payment due from the patient at the time services are rendered. Offer a script to front desk, clinical staff and patient schedulers Inform patient when on the phone or during a visit that there is a copay, patient will receive a bill, and there are different payment options Use appropriate language when collecting payment Ex: According to your insurance benefits, it shows that your financial responsibility includes a $ copay, % coinsurance, and a $ deductible

Billing for CCM CCM services may be billed by: Physicians Non-Physician Practitioners (NPPS): Physician Assistants, Clinical Nurse Specialists, Nurse Practitioners, Certified Nurse Midwives Rural Health Clinics (RHCs) Federally Qualified Health Centers (FQHCs) Hospitals, including Critical Access Hospitals (CAHs) *Note: only one physician, NPP, RHC, or FQHC and one hospital can bill for a patient during a calendar month

CCM Coding Summary Billing Code Payment Clinical Staff Time Care Planning Billing Practitioner Work Non-Complex CCM CPT 99490 Complex CCM CPT 99487 Complex CCM Add-On CPT 99489, use with 99487 CCM Initiating Visit (AWV, IPPE, TCM, or Other faceto-face E/M) Add-On to CCM Initiating Visit G0506 $43 20 minutes or more of clinical staff time in qualifying services Established, implemented, revised or monitored $94 60 minutes Established or substantially revised $47 Each additional 30 minutes of clinical staff time Established or substantially revised Ongoing oversight, direction and management Ongoing oversight, direction and management + Medical decision-making of moderate-high complexity Ongoing oversight, direction and management + Medical decision-making of moderate-high complexity $44-209 -- -- Usual face-to-face work required by the billed initiating visit code $64 N/A Established Personally performs extensive assessment and CCM care planning beyond the usual effort described by the separately billable CCM initiating visit

The Value of CCM Patients benefit from CCM: Team of professionals to help plan for better health Ex: monthly check-ins, ready access to care team improved care coordination Patients receive a comprehensive care plan May receive list of suggested resources and community services Patients using CCM will receive needed support between visits Ex: Regular touch point may help patients be more engaged in their treatment plan, opportunity to articulate the importance of self-care such as diabetes testing and medication adherence

The Value of CCM Practice benefits from CCM: Improved care coordination: practice will receive payment specifically for managing chronic care patients Support patient compliance and help patients feel more connected Ex: some professionals credit CCM with improving patient satisfaction and compliance, decreased hospital and ED visits Sustainability and growth Ex: may help sustain ongoing care management work, help find new patient resources

The Value of CCM Business case for billing for CCM services: Payment rate for CPT 99490: $42.84 Revenue per physician: o Average patient panel for PCP: 1,450 (American Board of Family Medicine) o 17% of total population Medicare-eligible (Kaiser Family Foundation) o 2/3 of Medicare beneficiaries have chronic conditions (CMS) o 1,450 patients * 17% of patients * 2/3 with chronic conditions * $42.84 per CCM patient ~$7,069/physician annually ($589/physician monthly) 20

CCM Reimbursement Scenario One LPN in the practice is responsible for CCM: Spends 20 minutes on the phone with 165 patients per month for CCM services Total time spent: 55 hours Average monthly hours for 1 FTE: 173.3 118 available monthly hours for other tasks (27 per week) Total revenue per month: 165 patients * $42.84 per patient = $7,069/month 21

CCM Reimbursement Scenario Monthly Revenue Potential % of CCM eligible patients: # of CCM Beneficiaries 100% 50% 25% 165 83 41 LPN Hours 55 28 14 LPN Gross Revenue LPN Net Revenue $7,069 $3,556 $1,756 $1,982 $(1,531) $(3,331) 22

CCM Methods in Practice

CCM Methods Prime Care Family Practice Utilizing Existing Practice Resources Bowie Internal Medicine Outsourcing via Technology Emporia Medical Associates Pharmacy Partnering

Utilizing Existing Resources: Prime Care Family Practice

Background: Prime Care Family Practice 7 clinician primary care practice in central Virginia Committed to starting CCM to: Provide a higher level of service to patients Create additional revenue stream Started with focus on Diabetes and Hypertension Began program by leveraging existing infrastructure and personnel Used nurse that was working on AWV and TCM to take over CCM

Barriers: Prime Care Family Practice Didn t think they had the time or resources to implement CCM Historically only had fragmented care management Engaging clinicians who already had a high degree of burden Difficulty efficiently scheduling patients Did not empanel patients patients going from physician to physician

Implementation: Prime Care Family Practice Clinicians continually review and modify protocols LPN manages patientcentered program Utilize EHR module to ID eligible patients LPN regularly communicates with patient to manage care Enrollment via shared decision making between patient and clinician Warm handoff to LPN who initiates care management activities

Results: Prime Care Family Practice Program Results Practice went from 1 billed CCM encounter in 2015 to 905 in 2016 Using existing infrastructure to build service Satisfier for patients and clinicians alike Success is reflected in quality scores compared to MIPS EHR benchmarks: NQF 0018 (Hypertension Control) 8th decile NQF 0059 (A1c Control) 9th decile 904 Additional CCM Encounters Billed from CY-2015 to CY-2016

Results: Prime Care Family Practice Better Care & Experience of Care Greater access to medical team Decreased risk of requiring ED or inpatient admission Lower long-term health care costs More Time at Top of License Reduced burnout thanks to team-based approach More productive visits for complex patients

Results: Prime Care Family Practice A Smooth-Running Practice Increased revenue stream from CCM billing Greater operational efficiencies Well-managed patients = happier patients Evidence of Transformation Developed patient and family-centered care design Optimized EHR Used data to drive change, improve operational efficiency, and use as a model for sustainable business operations

Outsourcing via Technology: Bowie Internal Medicine Associates

Background: Bowie Internal Medicine Associates 6 clinicians Serving community for 40 years Offers extended hours, patient portal Internally bills all of their own insurance statements and bills Incorporated the ideas and strategy of their whole team to make changes to CCM process

Barriers: Bowie Internal Medicine Associates Barriers to creating a CCM process: Developing a risk analysis system to determine whether patients could qualify for CCM Creation of a care plan documentation process through their EHR IMS/Meditab Documenting to support the coding of CCM codes 99487, 99489, and 99490 Calculating the time spent working with chronic care patients outside of their office visit appointments Distinguishing the level of decision making by clinicians regarding their patients

Implementation: Bowie Internal Medicine Associates Levering Technology: Chronic Care IQ CCM patients call CCM phone line Directed to provider s care team Length of call tracked and time stamped in patient chart Clinical staff makes any additional CCM documentation in chart via Chronic Care IQ CPT codes automatically generated and report able to be exported

# of CCM Services Billed Results: Bowie Internal Medicine Associates Chronic Care Management Services Billed 2000 Number of CCM Services Billed To Date Projection for CY-2018 1600 1200 800 400 0 93.4% Relative Improvement from CY-2015 to CY-2017 650 677 1257 1584 396 CY-2015 CY-2016 CY-2017 Q1-2018 Reporting Period

Results: Bowie Internal Medicine Associates CCM services resulted in: $ Increased revenue Improved continuity of care Better documentation Improved teamwork New leadership roles and responsibility Greater individual pride in work

Partnering with Independent Pharmacy: Emporia Medical Associates

Background: Emporia Medical Associates 4 clinicians High chronic care population Ranked 133 (last) in health outcomes in Virginia in 2017 Initiated CCM program partnering with an independent pharmacy first of its kind

Barriers: Emporia Medical Associates 1 clinician transitioning from paper charts to EHR 1 clinician out on medical leave Very busy, unsure how to incorporate needed service Pharmacy needed access to EHR

Implementation: Emporia Medical Associates 1. Recruit eligible patients 2. Create a care plan with a local pharmacy 3. Bill for CCM service 4. Reimburse pharmacy for CCM services and follow-up with pharmacy as needed 1. Monthly meetings with patient 2. Implements care plan 3. Reconciles medications and coaches patients 4. Coordinates data collection with practice 1. Monthly meetings with pharmacist 2. Medications are reconciled 3. Provided guidance for a healthy lifestyle 4. Provided tools for self-monitoring 1. CCM billing codes 2. Care plan 3. Patient education 4. Data collection

Resources: Emporia Medical Associates

Results: Emporia Medical Associates CCM services resulted in: Partnership with independent pharmacy 85% of patients kept CCM appointments 100% of patients reported improvement in quality of life after dieting and exercising Improved medication adherence and patient monitoring skills

# of CCM Services Billed Results: Emporia Medical Associates Chronic Care Management Services Billed 100 80 60 40 20 0 Implemented service as a pilot with emphasis on diabetes + 2 more conditions 0 Clinician on medical leave, but able to continue, but not spread 20 Baseline Q3-2017 Q4-2017 Q1-2018 Reporting Period 48 Continued commitment to service, expanding past diabetes 56 180% Relative Improvement from Q3-2017 to Q1-2018 Emporia Medical Associates has established an internal goal of billing 10 CCM services per clinician per month. This equates to a goal of 480 CCM services billed by the end of 2018.

Success: Emporia Medical Associates Patient Success: Patient A: did not know it was necessary to refrigerate insulin Patient now has better A1C levels Patient B: used same lancets for over a year, did not follow meal plans, did not maintain medication list Patient now has overall better health and less risk for infection

CCM Resources

Sample CCM Workflow

CMS Patient Postcard

Sample Comprehensive Care Plan

Key Takeaways CCM can help: Patients Better manage and understand their care, engagement Practices Improved teamwork, documentation, and empowerment Providers Reduced burnout and reimbursement opportunities

Testimonials of Success: Any service that is patient centered, but also adds revenue to our business is welcome. -Pharmacist Partner This is an extra resource on top of whatever we are able to do, so the patient has another person helping them control their disease. Lead Clinician

Resources CMS Resources CMS CCM Tip Sheet CMS CCM Resource Center CMS Patient Postcard Other Resources HQI Video: A Partnership in Chronic Care Management HQI CCM Toolkit ACP CCM Toolkit AAFP CCM Resources AMA Steps Forward

Contact Information Virginia Brooks, MHA, CPHQ Vice President, Physician Services 804.289.5320 vbrooks@hqi.solutions