Medicare Advantage. Annual Planned Visit Workbook

Medicare Advantage Annual Planned Visit Workbook

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-hmo benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

Table of Contents Getting Started 4-9 Worksheet A Get Ready! 10 Define data 10 Assess your access 10 Track and Monitor 11 Patient-Centered Planned Visit Model 11 Worksheet B Get Set! 12 Educate staff 12 Address Barriers 13 Worksheet C Go! 14 Worksheet D Keep Going! 15 Worksheet E Patient-Centered Planned Visit 16 Planned Visit Model 16 Worksheet F Use Data to Measure Success 18 Where will your data come from? 18 Data Wall 18 Appendixes 19 Sample Protocol for Annual Planned Visits 20 Worksheet A Get Ready! 21 Worksheet B Get Set! 23 Worksheet C Go! 25 Worksheet D Keep Going! 26 Worksheet E Patient-Centered Planned Visit 27 Medicare Glossary of Terms 30 Resources 32

Getting Started This workbook on the Annual Planned Visit will provide you great opportunities that will help in shifting your current strategies and operations from a reactive approach to a proactive approach in managing your patients and their needs. The demand for value-based care is encouraging providers to adopt a completely different technique in delivering care to their population. Instead of waiting for sick patients to alert you of medical needs, it will be beneficial to your practice to build a program, with clearly defined processes, that will proactively identify what your patients need, when they need it, and how to get it to them. Medicare Advantage Population Our practice has found that making time in our schedules for an Annual Visit is just as crucial to the success of the practice as having sick/same day appointments available. Starting the year off with an Annual Care Visit allows staff, physicians and the patient the courtesy of all being on the same page, and finding & discussing what needs accomplished for the year. Incorporating a plan that utilizes the disease management/health management function of the EMR has helped to streamline the process. The face-to-face encounter allows physicians to meet and speak with the well patient who is more receptive to discussions about needed screenings and lab work than when they are ill or pressed for time during a same day visit. Very few patients refuse this opportunity to speak with their physician and formulate a year-long plan! -- Cindy, Trumbull Mahoning Medical Group, OH The Annual Physical for this population allows the provider the opportunity to screen, assess and conduct a physical exam on their patients in order to collect data on medical, psychosocial, functional capabilities, and limitations of this population. The information collected during the Annual Physical is critical in documenting and coding to the highest level of specificity of the burden of illness, closing gaps in care and care planning with the patient to achieve their healthcare goals and to reduce cost of care. Note What Annual Planned visits are available to the Medicare Advantage patient? Annual Routine Physical (codes 99381-99397) is a Face-to-face comprehensive, multi-system exam based on the patient s age, gender and identified risk factors. The comprehensive history obtained as part of the preventive medicine service is not problem-oriented and does not involve a chief complaint or present illness. It does include a comprehensive system review and comprehensive or interval past, family, and social history, as well as a comprehensive assessment/history of pertinent risk factors and it includes clinical laboratory tests. This benefit is once per calendar year. Initial Preventative Physical Exam (IPPE) (code G0402) is a face-to-face visit; includes a preventive evaluation and management service. This exam is a preventive physical exam and not a comprehensive physical checkup or a routine physical exam. This service is limited to new beneficiaries during the first 12 months of Medicare enrollment. Initial Annual Wellness Visit (AWV) (code G0438) is a face-to-face visit; includes a personalized prevention plan of services. Services is limited to beneficiary during the second year the patient is eligible for Medicare Part B. Only one initial AWV per beneficiary per lifetime. Subsequent visit (G0439) is a face-to-face visit; includes a personalized prevention plan of services. Coded the year following the initial AWV. This benefit is once per calendar year. This AWV is not a routine physical exam. Can a separate Evaluation and Management (E/M) service be billed at the same visit as the Annual Physical? Medicare payment can be made for a separately identifiable medically necessary E/M service (Current Procedural Terminology (CPT) codes 99201-99215) billed at the same visit as the Annual Physical when billed with modifier -25. That portion of the visit must be medically necessary to treat the beneficiary s illness or injury, or to improve the functioning of a malformed body member. Annual Planned Visit Workbook 4

Risk Adjustment and the Annual Physical When caring for the Medicare Advantage patient, it is important to understand how risk adjustment impacts the health plan, the patient and the provider. Risk Adjustment is the process Centers for Medicare and Medicaid Services (CMS) uses for defining and funding future resources your patient may need. It is dependent on correctly assessing your patient followed by proper documentation, in the medical record, of the burden of illness to allow for appropriate coding to the highest level of specificity. In a risk sharing environment, under represented disease burden may make it more difficult to achieve shared savings and performance targets. With risk adjustment, the health status of the patient is calculated by using demographic and clinical diagnostic data information plus the clinical health status of the member. This is how payment is aligned with the expected medical costs and health care needs. Other benefits that result from appropriate documentation and coding include risk stratification and supporting the identified needs of this population. This information will help you strategically align your staffing and operations based on the needs of your population. Defining quality measures and monitoring your success is also dependent on appropriate documentation and data collection. Providers control the delivery of health care and impact to quality For Medicare Advantage, Risk Adjustment, HEDIS and Stars, success is all connected to providers controlling the delivery of health care and the impact to quality. Provider data and Medicare Risk Adjustment It is critical for providers to understand that diagnostic data, in the form of ICD-10-CM codes, are the basis of risk adjustment payments. The CMS-HCC model depends on coding specificity with the emphasis on diagnosis coding rather than Current Procedural Terminology (CPT) coding. Providers must follow these steps to assure correct risk adjustment: Produce appropriate medical record documentation -- According to the 1997 Documentation Guidelines for Evaluation and Management Services, medical record documentation must contain pertinent facts, findings and observations about an individual s health history including past and present illnesses, examinations/tests, treatments, and outcome. Assign the codes following the ICD-10-CM Guidelines supported in the medical record documentation. Report the ICD-10-CM diagnostic data to the Health Plan via claims submission or supplemental data. Annual Planned Visit Workbook 5

Documentation and Medicare Risk Adjustment All Medicare Advantage organizations and specialty plans are required to attest the accuracy of the Risk Adjustment data submitted to CMS. Providers must maintain precise medical records for every Medicare beneficiary, be aware of HIPAA guidelines and use standard Medicare coding rules and requirements. Coders can only code what is documented. To code to the highest level of specificity in compliance with ICD-10-CM guidelines, the documentation must be complete and detailed. The objective of thorough and accurate documentation in the progress notes is to help CMS evaluate the costs of taking care of the patient and to pay Medicare Advantage plans appropriately. ICD-10 and Medicare Risk Adjustment ICD-10-CM diagnosis codes have a critical role in the Medicare risk adjustment process. The CMS-HCC model requires ICD-10-CM diagnosis codes to calculate risk adjustment payments. Those codes also reflect the health status of a Medicare beneficiary. CMS requires the submission of all CMS-HCC relevant diagnosis codes from physicians, hospital inpatient facilities and hospital outpatient facilities. The guidelines must be followed at all times, and the ICD-10-CM code assigned to a diagnosis must meet the highest level of specificity according to the physician s documentation. Medicare Advantage Population Annual Physical and Risk Adjustment Annual Physical Complete once per calendar year Use Anthem's Annual Routine Physical/Preventive Medicine Services (99381-99397) Make appointments to see your Medicare Advantage patients (January April); allows time for follow-up and closing gaps in care Make follow-up appointments to address barriers, gaps in care, monitoring of care plan Prevention, Assessment and Care Planning Immunizations and preventive care Identify the patient s burden of illness Health Risk Assessments - structured way of identifying health issues and conditions that are potentially preventable or amenable to interventions in order to improve health and/or quality of life Care Planning - written plan with patient and/or family/caregiver. Advance Care Planning Barriers to care Gaps in care Treatment plan Medication Management Adherence Reconciliation High-Risk Medications Polypharmacy Documentation and Coding Document in medical record Medical record documentation impacts coding specificity and higher data quality Sign/symptom and unspecified codes have acceptable uses and are sometimes even necessary If a conclusive diagnosis has not been established by the end of the visit, it is correct to report codes for sign(s) and/or symptom(s) as a substitute of a definitive diagnosis If the clinical information is not sufficient, unknown or unavailable when assigning a specific code for a disorder, it is acceptable to report the proper unspecified code. It is inappropriate to select a specific code that is not supported by the medical record documentation. Annual Planned Visit Workbook 6

Planning for your other populations For other populations, the same approach can be tailored to those needs to ensure age appropriate services on preventive care, well visits, appropriate screenings, immunization/vaccines, and closing gaps in care are provided. Commercial Population All patients should visit their health care provider from time to time, even if they are healthy. These visits could fullfil these purposes: Well Child visits Prevention Screen for diseases and behavioral health Assess risk of future medical problems Encourage a healthy lifestyle Update vaccinations Maintain a relationship with a provider in case of an illness Management of high risk patients Chronic disease management Regular health exams and screenings can help find problems before they start or identify potential problems early when you have the opportunity to treat and mitigate progression of disease/conditions that may result in more costly care. When patients get the right health services, screenings and treatments, you are taking steps that will help your population achieve a longer and healthier life. To reduce cost, the best approach is to be proactive and spend more time on services that will reduce the need for unplanned care. Non Planned Care Planned Care Increase in ER, INPT, specialty care Safety issues Gaps in Care Progression of chronic disease Rising risk of chronic disease Increase in costs Improved patient wellness, quality of life and patient experience Adherence to treatment plan Proactive in identification and management of conditions Slowing disease progression; Chronic Condition Management Decrease hospital utilization, emergency room and acute inpatient care Lowered costs Annual Planned Visit Workbook 7

How do you get the most out of the Annual Planned Visit? Establish a quality improvement team with clearly defined goals and objectives, and begin putting processes and protocols in place to manage your Annual Planned Visit approach. Prepare for this visit by using the Patient-Centered Planned Care model to strengthen your infrastructure. Implementing the Patient Centered Planned Care model can mean the difference between physician and staff that are struggling and frustrated and one that runs smoothly with the capacity to handle any unanticipated issues that may arise. Planned Care across the Continuum of Health Infant/Child Adolescent/ Young Adult Adult Senior Well Visits Well Visits Vaccines Vaccines Immunizations Vaccines Managing rising risk Immunizations/ Vaccines Sports Physicals/or Employee Wellness Screenings (Blood pressure, BMI, etc.) Behavioral Health Screenings Women s Health Managing rising risk Preventive Cancer Screenings (Breast, Cervical, Colorectal) Employee Wellness Screenings Chronic Condition Monitoring/ Specific Screenings (ex. A1C, vision and urine protein for diabetes) Preventive Cancer Screenings Chronic Condition Monitoring/Specific Screenings Managing rising risk Behavioral Health Screenings Behavioral Health Screenings Managing rising risk Annual Planned Visit Workbook 8

Annual Planned Visit Strategy The focus of the Annual Planned Visit is to drive early assessment based on the population s needs. For your Medicare Advantage patients, capturing and documenting the patient s burden of illness, coding to the highest level of specificity, closing gaps in care throughout the year and establishing care plans are all activities that can be accomplished during the Annual Planned Visit. To be successful with your strategy, you will want to understand your current status and begin planning early in the year so you can design the best strategy for your population. Consider the below timeline as your roadmap to planning and implementing your Annual Planned Visit strategy. This timeline should work well for most visit types, specifically for patients with Medicare Advantage plans and your high-risk population. However, a practice can modify this timeline to work for any population by choosing a launch date and creating a strategy around it. For example, conducting adolescent well visits and sports physicals over the summer can prevent a back to school rush. Prioritizing your Annual Planned Visits throughout the year will ensure you achieve desired results for your entire population. Annual Planned Visit Life Cycle Get Ready! QI Team/Plan Data Access Tracking and Monitoring July - September October December Get Set! Outreach Workflows and Protocols Education Staff Go! Launch Annual Visits January-March April-June Keep Going! PDSA to modify program Measure your progress Make necessary changes Go to Get Ready! for the next year Annual Planned Visit Workbook 9

Worksheet A Get Ready! Time period: July September Get Ready! The focus here is on getting practices prepared to launch the Annual Planned Visit Initiative. This is the planning phase. Planning is one of the most important project management and time management techniques. It is preparing a sequence of action steps to achieve a specific goal. When done effectively, it can reduce the necessary time and effort for achieving the goal. Your practice can start by understanding your capabilities and patient population through process mapping and risk stratification. Process mapping is a technique that maps out the sequence of events, interactions, process steps, activities and tasks that make up an individual process, from beginning to end. This process allows you to own and improve your processes. Worksheet A- Get Ready! Annual Visit Other population ability to access achieve this? We re just getting started We ve been at this while What we plan to do Strategy Commercial (chronic condition), Wellness Other population ability to access checks or any visits that may be required Commercial (chronic condition), Wellness Quality Have you by developed Employer>? your QI Plan for Have you checks developed or any or visits updated that your may QI be required Improvement Annual Planned Visits? Plan for Annual by Employers? Planned Were Visits? you able to achieve Plan/Team to Do you have a team with regular meeting, Is your team this? still the right fit? Anyone new Drive Change vision, goals, etc.? to add? Tracking and Have you What Process will you Mapped use to your track current and monitoring Did you re-review Did you assess goals and your vision? method of tracking Monitoring state? alerts for patients Have you and Processed monitoring Map alerts to identify for patients any (update Have you Medical defined Record goals and vision? needed changes? medical record, registry/ehr, etc.)? Registry Medical Record Evidence-Based Identify Evidence Flags in EHR? Based Guidelines (EBGs) What EBGs Registry are you using to standardize Guidelines to standardize Anthem many Data of the tasks at your tasks at your Flags practice? in EHR? Are they working? (EBGs) practice. PCMS data Are your Anthem visits structured Data around EBGs for Are your visits structured around EBGs for your population? How will you communicate your progress PCMS data your population? to goals with the health care team? Have you Was defined your metrics team receptive to ensure to EBGs your Medicare are followed communication by the Healthcare efforts Team on goals? with Adult every age group in your population? Close Gaps in Pediatric What gaps in care will you focus on as a Review: Care Have you team? defined metrics to ensure EBGs Last year s RAF and outcomes (for MA) are followed How by will the you Healthcare engage the Team patient with and PCMS every age educate group in on your the population? value to closing gaps in GIC, Annual Planned Visit Dashboards care Scorecard results quality metrics Data What data Do do you you have have alerts available? in your system What data have you and used? cost of What care other data How will you Is staff identify prepared patients to explain you are what their is available? going to target? benefit covers, or recommend they Did you perform a post-mortem on Medicare contact Advantage insurance company previous year results? Evidence 19 to 65 yo Were you able to meet your targets Based Guidelines for: Birth to Prevention 18 yo Did you look at the historical impact/ and wellness How will you Care risk stratify Opportunities population and trending by month? prioritize visits by importance, severity Have you set new measures to Immunizations and vaccines level/high-risk. continue to improve? Chronic Condition management Review: SMART Goals Do you have Medical goals established Record for your Do you have goals established for your population? PCMS population? Are they measurable Registry and have they been How well did you achieve goals last year? communicated GIC, to Annual the healthcare Planned Visit team dashboards What new goals will you put into Do you have buy Scorecard in from the results provider quality metrics place to improve results this year groups on the goal and cost of care Focus on Do you have a Comprehensive Medication Did you assess your Medication Access Medication Have you Management conducted an Strategy? assessment to Did your Management access plan work? Strategy? What worked? Management determine Do if you you prepare can meet patient the access to bring in all of Were there What months/days/hours changes can you make? that were demands their of the medications annual planned (Rx, OTC, visit? supplements, better than Have others? you considered comprehensive Medicare inhalers, Advantage insulin, completing topicals)? all visits Medicare medication Advantage review completing with pharmacist all visits or Jan-April Do of every you arrange year? time to complete Jan-April other of every qualified year? health Were you care able professional to for medication history interview? Medication patients with complex medication reconciliation, assess adherence and regimens? knowledge of medications? Some benefits of Process Mapping are: Spotlights on waste Streamlines work processes Defines and standardizes Promotes deep understanding Builds consensus Risk stratification is a process necessary to properly identify patients with the highest risk and those with minimal risk. It will assist in prioritizing the Annual Planned Visit and the needed interventions that will produce desired outcomes. Most Medicare Advantage and high-risk patients need to be prioritized and seen earlier in the year to allow your practice time to develop a care plan addressing the individual needs of the patient and plan the necessary interventions to ensure they are successful throughout the year. Define your interventions around evidence-based guidelines and physician input to ensure you address the needs of your entire population. This will help in identifying gaps in care related to prevention, immunizations/vaccines, treatment regimens, medication adherence, and potential barriers to care. Getting ready is the biggest part of the entire strategy and will be most successful when you have committed staff to concentrate on the Annual Planned Visit Initiative. Form a quality improvement team to provide the structure you will need to be successful and achieve sustainable results. Annual Planned Visit Workbook 10

Define data Data is a powerful tool to define your baseline and to establish SMART goals to monitor results. Most practices have timely data from the medical records that will complement the Anthem data. Leveraging this data helps you define opportunities to drive improvement. Assess your access When patients are unable to get timely appointments, it will have great impact on their success and yours. Limited access to their primary care provider can influence patients seeking unplanned care and increase overall costs by using high cost alternatives. When reviewing your access capabilities consider: Clinic approach (designated day/period of time dedicated to Medicare patients) Week end or extended hours Assess unplanned visits: Ambulatory sensitive admission, Avoidable emergency room visits and all admission that were unplanned related to chronic condition management (CHF, Diabetes, etc.) Advanced access (same day visits) Supply and demand analysis Home visit patients who are home bound Telehealth can be a method to treat those with non-serious acute care needs. Note: Telehealth will not work for closing HCC gaps; risk adjustment data is collected from face-to-face encounters with a CMS acceptable provider Awareness of barriers and challenges Social determinants (e.g., elderly) Process mapping to eliminate waste and improve efficiency Track and Monitor Track and monitor your goals frequently, make needed process changes and communicate frequently to the health care team to continue the momentum and focus on the initiative. Run reports from your EMR system to track the number of visits scheduled and the number of visits completed weekly, as well as, monitoring patient refusals, the successful closing of gaps in care, documentation needs and the identification of providers with access challenges. Anthem data can be used as a source to monitor your progress to ensure you are meeting defined goals. The Get Ready worksheet is a tool to assist you with this process. It contains examples of questions that may help you in understanding both your current capabilities in delivering high-quality value-based care and what your patient population looks like. Consider leveraging EPHC program resources, including ACP Practice Advisor, to support focused improvement in these areas. Patient-Centered Planned Visit Model The Patient-Centered Planned Visit model is a proactive approach to care that ensures each visit is meaningful and well organized by shifting administrative tasks out of a patient s appointment time so team members can focus on the patient and not the paperwork. This simply means less time shuffling papers and more real time with the patient. With pre-visit planning, providers have the information necessary at the time of the visit, and the care team can address the patient s needed services based on evidence-based care and provider guidance. Looking ahead at the schedule can allow your health care team to arrange for tests or equipment that would be required for the patient visit. You will find more details on this model further in the workbook. Annual Planned Visit Workbook 11

Worksheet B Get Set! Time period: October December Get Set! The focus here is on defining protocols and workflows, developing outreach strategies and start communicating your plan with your staff on the expectations and value of the Annual Planned Visit. This is the when you will be pulling all the pieces together that need to be in place before beginning to see patients for their Annual Planned Visit. Define your protocols and workflows to assist the health care team in implementing the plan. Test each step to ensure it is reasonable and will produce the results you need. Engage the staff to identify barriers to the workflows/protocols before you fully implement the plan. During this time, you will want to determine the appropriate assessment tools you will use, such as Health Risk Assessments, assessment for fall risk, dementia and behavioral health issues. Assessment tools can provide guidance Outreach (Practice) Medical Neighborhood Address Barriers Educate Staff Schedule preventive screenings Have you begun to build and communicate with your Medical Neighborhood/Community Resources? For example: Established care contacts with : Local pharmacy immunizations, etc. Specialist Care Hospital admissions or ER visits Urgent Care SMS Transportation Have you identified potential barriers such as language or socio-economic issues (income, literacy, rural)? Did you develop strategies around addressing a diverse population (age, gender, ethnicity, race)? Did you review best practices to overcome barriers? Can you identify resources to assist patients (i.e., transportation)? Did you review and assess Medical Neighborhood are your patients needs being met? Are there gaps? Do you need a Care Compact? What worked? What changes need to be made? Can you identify new opportunities for partnerships? Did you review outreach and education plan from previous year? Are you getting the results you want? What barriers is your practice aware of? What resources do you have to address? Have you: Did you: Created Education and Communication Assess effectiveness of Education and Plan for Staff Communication Plan for Staff Messaged the importance of the Annual Remind staff of messaging the Planned Visit importance of the Annual Planned Visit Educated providers on correct Put correct documentation, coding documentation and coding protocols protocols in place Educated your staff on health care Educated your staff on health care disparities disparities Implemented measures to improve Implemented measures to improve communication with your patients (selfmanagement, motivational management, motivational communication with your patients (self- interviewing, teach back, cultural interviewing, teach back, cultural competency, etc.) competency, etc.) Did you incorporate evidenced based Did you review how successful you were with guidelines in your review: ensuring all patients have completed their Prevention screenings by appropriate screenings? age groups Did you find that there were any barriers that Ensure the information if available to the need to be addressed? healthcare team to include during the visit Define processes that assist the patient in scheduling the appointment Schedule the appointment for them Follow up to ensure the appointment was completed to you for offering clinical preventive care, health promotion, and disease management services. They can help you improve health outcomes by identifying patients with health risks to provide follow-up. (see Resource Section) Educate staff As you are getting set to launch your Annual Planned Visit initiative, this is a good time to ensure everyone involved understands the goals and objectives and their role and responsibilities in guaranteeing you have success. Communicate frequently with the health care teams and quickly modify processes that are not producing desired results. Capture and report supplemental data for your Medicare Population to support closing gaps in care. Supplemental data consists of non-claims data and may include data received from labs, vendors and documentation contained in your own provider medical records. This is important because claims data does not close all gaps in care and some measures can only be closed by submission of supplemental data. Develop your communication and outreach strategies to engage your patients and start scheduling patient visits. Use Shared Decision Making (SDM) to improve communication with your patients. SDM occurs when a health care provider and a patient work together to make a health care decision that is best for the patient. Evidence suggests that shared decision making benefits the patient (improves satisfaction with care) and the provider organization (improves quality and may reduce costs). Annual Planned Visit Workbook 12

Define what your process will be for outreach; contacting patients for appointments, scripting on how-to communicate the value of an Annual Planned Visit. You will also need to be prepared to address no shows, cancellations and refusals to stay on track and achieve your goals. All attributed patients need to have an Annual Planned Visit even if you have not seen them before. They could have selected you as a PCP during the enrollment period. Assist your staff on how-to handle each situation and the expectations. Ensure to include a strategy to pursue collaboration with your Medical Neighborhood for timely information sharing on your patients. This information will be critical when you are assessing information and provide the health care team a holistic view of the services your patient is receiving. The Annual Planned Visit Toolkit has great resources for patient telephonic outreach and letter campaign scripting. Consider other means of outreach including text messaging, portal reminders, IVR (Interactive Voice Response) calls, and face-to-face patient messaging while defining processes to follow-up on no shows and future appointments. Outreach and communication is not a one size fits all solution and should be tailored to meet patient needs. Address Barriers Practices need to be aware of the impact to patient care related to health and health care disparities. The differences in health and health care between population groups occur across many dimensions; including race/ethnicity, language and literacy, socioeconomic status, age, location, gender, disability status, and sexual orientation. Disparities in health care: May limit overall improvements in quality of care and health for the broader population and result in unnecessary costs Account for barriers that prevent patients from getting into your office or following medical advice Can surface provider factors that encompass issues such as provider bias and cultural and linguistic barriers to patient-provider communication Can be a barrier to achieving your results in quality of care and lowering cost of care During this timeframe, begin scheduling the Medicare Advantage population to have their appointments between the January through April timeframe every year. The Medicare Advantage 2017 plan covers one calendar year comprehensive physical which allows you to see patients early, define a care plan with the patient on how-to address gaps in care, and schedule preventive screenings and immunizations/vaccines throughout the year. You can use this Get Set! worksheet to help assess your practice to determine what you currently have in place and what you may need to build into your practice. You can also find sample outreach letters and call scripts in the Annual Planned Visit Toolkit. Annual Planned Visit Workbook 13

Worksheet C Go! Time period: January-March Go! The focus now is to launch your Annual Planned Visits strategy and begin scheduling the next patient group you defined during your risk stratification process. You have your plans in place and now you are rolling out your Annual Planned Visits strategy. Use small tests of change (PDSA cycle) through your entire process to make sure you are getting the results you expect. Worksheet C Go! Annual Visit Strategy Patient Centered Planned Care Visit Model to conduct visits Launch Annual Planned Visit We re just getting started We ve been at this while What we plan to do Do you utilize pre-visit planning? Highly recommended to improve quality health outcomes and impact overall cost of care How will you Conduct visits for all attributed patients Document Burden of Illness and monitor that it was captured and coded appropriately? Medication Review/Reconciliation/Adherence Capture and submit supplemental data? Fax, Remote (EMR), FTP (File Transfer Protocol) or MFG (MyFile Gateway) Engage the Patient define barriers to their success Plan to discuss recommended screenings/schedule and the patient s risk Explain the tests/help with the patients fears or understanding of the value it brings to managing their healthcare Define a care plan with the patient on next steps in their healthcare plan Schedule follow up visit if needed (Annual Planned Visit) Address no shows Schedule next priority patients Do you utilize pre-visit planning? As you launch your program, start to monitor the results of your interventions: Patients are being seen as planned Gaps in care are being addressed and closed Prevention Immunizations/vaccines Medication Management Chronic conditions managed Care planning completed with patient/family input All attributed patients scheduled No shows and cancellations rescheduled Ensure your documentation supports coding of burden of illness (Medicare Advantage) Begin outreach to schedule your other age appropriate Annual Planned Visits. Immunizations/vaccines Non Medicare Advantage high-risk patients Sports physicals Child/adolescent well visits Young adults Prevention Chronic condition monitoring Highly recommended to improve quality health outcomes and impact overall cost of care How did you Conduct visits Document Burden of Illness Medication Review/Reconciliation/Adherence Capture and submit supplemental data? (Did your method work well for you?) Engage the Patient Plan to discuss recommended screenings/schedule and the patient s risk Explain the tests/help with the fears Define a care plan with the patient on next steps in their healthcare plan Schedule follow up visit if needed (Annual Planned Visit) Address no shows Schedule next priority patients For the Medicare Advantage population, this is the opportune time to assess and document the burden of illness in the medical record to allow for coding to the highest level of specificity. The burden of illness does need to be confirmed annually, so accurate documentation helps you assess and reassess your patients for proper coding. When this is done correctly, Medicare receives the right information and Anthem receives the accurate payment to cover the predicted health costs of the patient. You can use this Go! worksheet to assess your readiness to use the planned visit model and your plans to conduct the Annual Planned Visits. Annual Planned Visit Workbook 14

Worksheet D Keep Going! Time period: April June Keep going! The focus here is to assess what is working and what is not. Now that your practice has launched your Annual Planned Visit strategy, you will need to reassess your plan to see if it is working the way it was intended and evaluate what changes need to be made to the process. The Annual Planned Visit will continue to be a focus for your health care teams to address the needs of all patients in achieving their health care goals. This focus will impact the quality of care you provide your patients and lower cost of care by mitigating the need for unplanned care through proactive approaches in managing your population. Worksheet D Keep Going! Annual Visit Strategy PDSA to modify program Measure your progress We re just getting started We ve been at this while What we plan to do Did you Revise and test your plan Modify and adjust Monitor your performance and outcomes Throughout the year, are you continuing to meet your expected targets? Are you using QI tools (PDSA) to ensure the program is on target? Did you Have you Identify what information you have available Reviewed data and define new goals/metrics or need to develop to measure your success Refined your interventions to ensure you are PCMS achieving your outcomes EMR Communicated changes with the healthcare Registry team other Define your baseline Review data quarterly to assess your impact to goals Share findings with the health care team Define and communicate needed changes to ensure you achieve your outcomes Start planning Next Year s Work Plan (plan for next year s for the next year AV campaign) Next Year s Work Plan (plan for next year s AV campaign) Have you done a current year Post Mortem (what worked, what did not work) - failures and feedback, trends and opportunities, exclusions? Use PDSA cycles to address opportunities for improvement that were identified during the launch. The PDSA template provides primary care practices with a simple analytical methodology for testing ideas that can lead to improvements. (see PDSA template Appendix) Measure your progress by reviewing all data/information available to you to monitor if you are achieving SMART goals Make necessary changes to continually improve your processes Communicate results with your entire team to stay focused Get your practice ready to develop strategies for the following year This Keep Going! worksheet will help assess the process and identify any changes your practice may want to make. Annual Planned Visit Workbook 15

PATIENT CENTERED M E D I C A L H O M E Transforming Healthcare One Neighborhood at a Time Worksheet E Patient-Centered Planned Visit Planned Visit Model This is a great diagram/tool from HealthTeamWorks that provides a comprehensive framework for Patient-Centered Planned Care. It represents a move from reactive care to proactive care. Proactive care requires having systems in place before, during and after the visit this is called planned care. While we can never totally mitigate surprises during a patient visit, planned care allows a provider to manage a patient s continuum of care the most effective way possible. Patient-Centered Planned Care decision making Gather Patient Experiences coach and SM support review patient experience implement plan progress/symptom assess barriers/stressors monitoring Pre-visit planning allows the health care team to collect support change medication assessment self-efficacy Improved Outcomes valuable information needed at the time of the visit. Then Increased Healthy Behaviors Improved Quality, Safety, and Clinical Outcomes Increased Collaboration between Patient, Care Team, and Medical Neighborhood Adapted from: Improved Physician and Staff Satisfaction and Retention www.newhealthpartnerships.org Copyright 2009 HealthTeamWorks. All rights reserved. Reduced Cost Trends your health care team can address the patient s needed services based on evidence-based care you defined when creating your strategy on Annual Planned Visits. Looking ahead at the schedule can allow your practice staff to arrange for tests or equipment that would be needed for the patient visit. During the Pre-visit Planning, practices should: Gather important patient data Schedule diagnostic testing as needed for chronic care management Discuss patient health care needs during practice team huddles During the visit, practices should: Review pre-visit questionnaires Worksheet E Patient Centered Planned Visit Worksheet After the visit Complete the physical Example questions: 1. Develop processes and protocols on monitoring patient Reviewed or New Actions or Steps to Take What to review, adherence: and establish protocols and workflows Completed examination Overall Patient Centered A. Monitor 8. Plan Plan Visit patient appointment follow-up and conduct Team Huddles to review and exchange i. Medical neighborhood 1. Create or review current information for the days schedule ii. Referrals planned visit specialist, model and behavioral update or support, define strategies and processes A. Define the agenda for huddles Use a visit check list to ensure community for success based resources B. Discuss patient healthcare needs Develop and deploy B. Outreach a communication C. Adherence to high risk to and patients treatment education/training to ensure plan they plan are making on the new/updated progress model D. Barriers to goals to care all components of the visit is E. Lab/testing values C. Define F. roll Updates of Care from Management/Coordination Consider staff education: previous visit or recent visits to hospital, activities/protocols/staff Motivational specialists etc. i. Interviewing Self-Management Support achieved Shared Decision 9. ii. Define Care Making workflows, planning protocols and responsible staff Self-Management A. Rooming a) Support High-risk patient patients Quality Improvement b) i. Chronic Processes Medication condition Management management Assure most optimal coding is c) ii. Rising Allergies Risk patients 2. Pre-visit planning d) iii. Coordinating Prevention with Screening the Medical needs Neighborhood iv. Immunization needs D. Resources and happening at the time of the v. solutions Questionnaires to barriers 1. How will you conduct outreach and appointment based reminders? on defined protocols 2. Define workflows E. Define and how protocols vi. you Advanced will for manage the entire Care the Planning/Directives healthcare Medical Neighborhood, team referral activity, vii. New unplanned complaints? care at hospital/emergency 3. Ensure you have room all and the appropriate urgent viii. Prepare care. assessments for exam lined up to visit (this can be supported do (HRA, PHQ2 9, etc.) B. Define the hand off to physician (brief updates to MD to 2. Develop quality improvement help focus the plan MD visit to monitor and meet success: the needs/expectations 4. Use of standing orders of the patient) A. Laboratory A. Identify quality improvement projects and define predetermined testing metrics with EHR alerts or visuals) B. Diagnostic Review metrics to ensure (i.e., A1c you monitoring are achieving rate established for diabetic goals on C. Prevention pre-visit patients) screening planning D. Immunizations/Vaccines Establish protocols on During B. Review the visit data to determine intervention success 5. 3. Determine Define who 3. Data and Identify you what will will information use collect to measure information and processes/protocols success needed and progress: to for during the visit: conduct the visit A. Staff responsibility A. To ensure A. Develop you are a getting checklist the to results ensure you patient expect, receives you need the Medication Management B. Medical record to constantly review required review care data during and make the visit changes to achieve C. Lab results your noting goals abnormal for each results patient population D. ER visits, Hospitalization i. B. Medicare Prevention and Annual and specialty Screening Planned notes Visit, by appropriate recapture rate, age group Adherence E. Current medication closing gaps in care, care planning for patients with C. Comprehensive list exam - review test results F. Known barriers chronic for patient conditions. G. Gaps in care ii. D. Medicaid Develop a High-risk, care plan closing with the gaps patient in care, on their care goals and planning the provider for patients goals with chronic conditions. Reconciliation H. Chronic conditions or rising risk 6. Define age appropriate E. Self-Management questionnaires/assessment Support tools needed to assess patient i. status Gaps in care Use self-management support ii. Chronic Conditions 7. Define what Anthem data iii. will Medication be accessed Adherence/education for gaps in care, utilization, care opportunities, iv. Appropriate other level of care, how and when to call their MD and patient education for F. Define follow-up strategy i. Schedule required testing ii. Make follow-up appointments patient self-efficacy and G. Review metrics to ensure you are achieving established goals on what happens during the visit confidence Formulate care plans and communicate with patient and family, and define a follow-up plan with the patient/caregiver Determine if referrals are needed Assist the patient with making appointments to close gaps in care by visit by e-mail by phone Access Front Office build relationships explore needs and preferences collect administrative info. Nurse/MA initial screening standing orders flow sheets Provider (MD/PA/NP)/Care Team set shared agenda for visit review chronic, preventive, acute care issues collaborate to set SM goals create care plan using shared Before the Visit 1 2 Team-Based Care During the Visit Leadership CARE PLAN Prepared Care Team labs/screenings team huddles specialist reports Self-Management Support Technology Care Plan Management/Coordination Care Coordin ation After the Visit 3 Population Management registry/reporting outreach prioritize population Follow-Up test and referral tracking review/revise plan problem solve Medical Neighborhood (co-located or referred) specialists mental health dental/vision services hospitals pharmacy community resources social work home health complex case managers peer programs other ancillary services Annual Planned Visit Workbook 16

After the visit, practices should: Have a process for the health care team to ensure gaps in care are being closed Review documentation to ensure the burden of illness is captured and ready for proper coding Address any barriers to care with the patient and/or family Refer to in-network providers and those who use low cost options when treating patients. This is for all providers in the medical neighborhood including specialists, behavioral health support, and community-based resources. Ensure they send you information about the visit and treatment plan (define care compacts). Then monitor patient progress, and completion. Annual Planned Visit Workbook 17

Worksheet F Use Data to Measure Success Without knowing in advance what success looks like, it is very difficult to implement any plan. Identifying measures of success and collecting data creates a common language that sets shared expectations within your working group. Knowing what success looks like makes it easier to implement your plan. Measures of success should tell you if your goals have been achieved with the results you expected or you may find it produced results you didn t want or expect. In that case, you will want to know as soon as possible to review your processes to ensure you are achieving the desired results. Where will your data come from? You have the patient s medical records and potential reports from your electronic health records to use. You also have great information provided by Anthem that is located on the Provider Care Management Solutions site (PCMS) a web-based application to help you manage your patients health and to thrive in a value-based payment environment. This data will support your overall goals for you Annual Planned Visit initiatives. PCMS reports: Attributed population including annual visit flag and clinical documentation indicator Utilization including ER and Inpatient Patient cost and utilization Hot Spotter for high-risk population Care Opportunities Claim based reports available from Care Consultant: Gaps in Care Annual Planned Visit Data Wall Create a data walls to communicate success and to keep the team focused on your goals and objectives. Below are sample charts that can be easily created to show monthly updates and keep the team aware of how they are doing. Data Wall Example Annual Planned Visit Workbook 18