1. How to add a Health Education Specialist/Health Coach to a Family Medicine Practice M. Lee Chambliss, MD, MSPH Suzanne N. Lineberry, MPH, MCHES

2. Disclosures Neither presenter has any conflict of interest or disclosures for this presentation.

3. Objectives Introduce what a Health Education Specialist is. Describe what a Health Education Specialist role is in a primary care practice. Demonstrate how to pay for a Health Education Specialist in a fee for service system. How to use a Health Education Specialist to achieve PCMH certification.

4. Problem Our Quality Improvement numbers plateaued (despite Patient Center Medical Home certification). We squeezed as much as we could out of the traditional provider/patient office visit. How to hire additional team members in a fee for service environment?

5. Opportunity Noticed that Medicare allowed Health Educators to perform Annual Wellness Visits (AWV) independent of direct physician involvement. Annual Wellness Visit –Medicare introduced three new Part B benefits over the last few years. –These include the Initial Personal Prevention Exam (IPPE), the Annual Wellness Visit (AWV) and the Subsequent Annual Wellness Visit (sAWV). –These visits are designed to promote and improve patient health and prevention.

6. Solution Quoting directly from Medicare: “Who may perform the AWV? A health professional, meaning a physician (a doctor of medicine or osteopathy), a qualified non-physician practitioner (a physician assistant, nurse practitioner, or certified clinical nurse specialist), or a medical professional (including a health educator, registered dietitian, nutrition professional, or other licensed practitioner), or a team of such medical professionals who are working under the direct supervision of a physician, must furnish the AWV.” Resource: Medicare, The ABCs of providing the annual wellness visit, January 2012

7. Why not hire an RN? Nonmedical professionals have demonstrated they can work well in primary care environments. A health education specialist is specifically trained in behavioral theory and can implement interventions on a personal level as well as for the entire practice population. A health coach who does not have patient care background is free to focus solely on patient education and motivation. –There will not be the temptation (or patient expectation) to provide traditional medical care or answer the inevitable medical questions that occur during coaching sessions. –Nonmedical health coaches can more easily refer illness complaints back to the patient’s provider and thus stay focused on the patient’s behavioral coaching.

8. Clinical Innovation 1.Expand the current care team model with a Health Education Specialist (HES). 2.Collaborate with local university’s department (UNCG) of Public Health to create job description and identify potential applicants. 3.Hired a master prepared HES with an additional health coaching certification. 4.Created office space for HES. 5.HES started with AWV’s.

9. Health Education Specialist Roles RoleJob DescriptionTraining Health educatorConduct annual wellness visits and act as patient resource and educator. Bachelor’s or masters degree in public health, community health, or health promotion. Health coachConduct co-visits; work with physician and patient to clarify health goals, motivate behavioral change, create accountability, and follow up; act as physician scribe. Health coaching certification Practice quality coordinatorAssess, plan, implement, and evaluate practice patient quality measures, such as patient- centered medical home (PCMH), meaningful use of health information technology, and Affordable Care Act Requirements. No specialized training programs. Recommend minimum of a bachelor’s degree. MPHs, MBAs, and registered nurses have performed this role in the past.

10. Co-Visit Algorithm

11. HES Reimbursement Billable ServiceWho Performs Service Physician TimeHealth Education Specialist’s Time Reimbursement Rate* Initial Prevention Physical Exam (IPPE, Welcome to Medicare Visit) Physician + Health Education Specialist 15 minutes to meet with the patient. 45 minutes$156-165 Initial Annual Wellness Visit Health Education Specialist 2 minutes to review documentation 1 hour$161-170 Subsequent Annual Wellness Visit Health Education Specialist 2 minutes to review documentation 30 minutes$108-114 Health Coaching co-visits Physician + Health Education Specialist 4-8 minutes to meet with patient, complete chronic disease follow- up, HPI, assessment, and plan. 30 minutes plus weekly phone calls $43-107, depending on level of service charged * Based on nongeographically adjusted Medicare rates

12. HES for PCMH recertification Previous box clicking for PCP did not show improvement in patient’s health. Identified high risk sub-populations to focus on PCMH requirements. –≥9 A1C –At high risk for falls –Ready to quit smoking –Two BP readings ≥ 160/100 HES identify patients on daily schedule. PCP refer these patients to team members after their visits. Team members fulfill PCMH requirements, use MI skills and set health goals with patients. Patient follow up phone calls and appointments with team members.

13. PCMH Patient Stories Mr. Thomas and the Nicotine Train The Trouble with Colonel John

14. Our Practice’s Experience 2012 –Performed AWVs on 211/800 patients > 65 years old Billed $32,000 AWV no shows rate 16% –25 co-visits 2013 –Performed AWVs on 129/1200 patients (all ages) –50 co-visits –QI conference projects (I3POP) 2014 –Performed AWVs on 28/1200 –50+ co-visits PCMH related –PCMH level 3 recertification awarded –Meaningful Use, ACO, Resident QI projects, I3POP

15. Summary Opportunities for improvement around patient care were identified. Decided to add additional team members in fee-for-service world. Medicare AWV’s allow for Health Educators to provide service. Hired a Health Education Specialist (HES). HES facilitates Annual Wellness Visits, Co-visits, and QI projects. We have received reimbursement for visits. We have received PCMH certification, with minimal PCP interruption and patient improvement.

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