1. Medicare Chronic Care Management Building an Inter-professional Medical Home Team to Improve Care Coordination for High-Risk Seniors Shaylee Peckens, MD, PCMH CCE West Virginia University Gregory Castelli, PharmD Department of Family Medicine Karen Fitzpatrick, MD, PCMH CCE Rachelle Peklinsky, A.P.R.N.

2. Pre-assessment What is your practice’s current state of CCM? Not existent, I am here to learn In the planning stages, I need ideas Active CCM service, I am here to show how far superior we are If in planning or active stage, who are the members of your team?

3. Session Objectives By the end of this session, active participants will be able to: 1.Define CMS requirements for care delivery and billing of new CMS Chronic Care Management (CCM) Codes 2.Discuss establishment of an interprofessional team for CCM 3.Identify how care coordination services can improve population health and quality

4. Session Outline Background The Rule CCM at WVU Team Dynamic/Re sults Summary/N ext Steps

5. Session Outline Background The Rule CCM at WVU Team Dynamic/Re sults Summary/N ext Steps

6. Academic Family Medicine Program, Level 3 NCQA PCMH Hospital-operated clinic within large health system in northern WV 6-6-6 residency, PCMH Fellowship 17 faculty physicians, 3 physician assistants, 4 APRNs 10 Medical assistants, 6 LPNs, 5 RNs, 3 RN case managers 35,000 visits per year/ 14,000 unique patients Epic EHR across health system

7. Progression to team-based care coordination PCMH redesign Nurse Case Management APRN Wellness Coordinator PCMH Pharmacist Chronic Care Management TEAM Data for Risk Stratification Medicare Population Data Team-based Care

8. Session Outline Background The Rule CCM at WVU Team Dynamic/Re sults Summary/N ext Steps

9. Why now? Patient’s with multiple medical conditions, limited functional status, and psychosocial needs account for a disproportionate share of health care cost and utilization. The Centers for Medicare and Medicaid Services (CMS) recognized care management as one of the critical components of primary care that contributes to better patient care and reduced spending.

10. Chronic Care Management Medicare began reimbursing for chronic care management (CCM) services January 1, 2015 Separate payment for non face-to face care management/ care coordination

11. CPT code 99490 20 minutes of non-face-to-face care coordination services per calendar month by “clinical staff” for eligible patients

12. Eligible patients Medicare beneficiaries who have two or more chronic conditions

13. Billing Providers Physicians Other Qualified Healthcare Professionals (QHP) Nurse practitioners Physician assistants Clinical nurse specialist Certified Nurse Midwives

14. Clinical Staff Member Under the supervision of a physician or other qualified health care professional “Incident to” exception (general supervision)

15. Billing Cannot overlap with: Transitional Care Management (TCM) Hospice Skilled nursing Other care management services Once per calendar month Only one provider

16. Enrollment Discuss at comprehensive face to face visit with billing provider visit (AWV, IPE, TCM, 99215) Explain CCM services Document discussion in EHR/visit note Explain payment for CCM How to revoke services One practitioner per month can bill EHR communication and sharing of medical information with team (all requirements for the informed consent)

17. Consent Written consent does NOT have to be signed at that visit Signed by BILLING practitioner Only obtained once

18. Scope of Services Communication with the patient during care transitions Coordination of care with other treating health professionals Comprehensive electronic care plan Medication management Improved access to care

19. Session Outline Background The Rule CCM at WVU Team Dynamic/Re sults Summary/N ext Steps

20. Team-Based Care Coordination The Primary Care Provider Two Nurse Case Managers APRN & Wellness Coordinator Clinical Pharmacist CCM Physician Leaders Ancillary CCM team members Clinical Dietitian Social Worker Triage Nurse Billing Specialist

21. Chronic Care Management: The Process Case Management updates plan of care as needed Identify Patients Obtain Consent Team notified of patient enrollment Clinical Pharmacist conducts comprehensive medication review Case Management begins individualized plan of care

22. Enrollment Process CRITERIA Charleson Index Report >2 co-morbid illnesses estimated to last at least 6 months Medicare patient PCP INVOLVE- MENT Distribute patient list to PCP OUTREACH Wellness Nurse Practitioner Outreach Make appointment for AWV, TOC (if indicated), or level 5 visit

23. Consent Performed during the following visits according to the rule: Annual Wellness Visit Transitions of Care Visit post-hospital discharge Level 5 Office Visit Consent Criteria 1.Nature of CCM 2.How CCM team can be accessed 3.Only one practitioner can furnish the CCM services at a time 4.That the patient’s health information will be shared with all team members involved in his/her care 5.The service can be discontinued at any time Challenges Developing consent was a barrier Compliance & forms committee Tedious process Challenges Developing consent was a barrier Compliance & forms committee Tedious process

24. Must be available 24/7 to both the patient and care team via EHR and updated regularly Problem list, expected outcomes, measurable goals Symptom management & interventions Community/social services utilized Plan of coordination with other providers Medication Management Responsible individuals for each intervention Requirements for periodic review/revision -Core Elements- Plan of Care

25. Our CCM Process Plan of Care updated and shared Educational Information Distributed Medication Reviews Access to Fast-track appts 20 minutes non-face-to- face time spent per month PCP INVOLVEMENT

26. Steps to Success Weekly meetings prior to initiation of service Meeting with compliance & EHR specialists Access to our Medicare Advisor CCM team “start small” Utilization of resources

27. Session Outline Background The Rule CCM at WVU Team Dynamic/Re sults Summary/N ext Steps

28. Weekly Team Meeting Team meets for 1 hour weekly Goal is to coordinate patient care and CCM service Tools: Access to EHR Projector Spreadsheet Coffee/lunch

29. Weekly Team Meeting Review care plans for the list of patients Discuss any patient issues Identify new enrollees Ensure proper charge capture Discuss scholarship

31. Patient PharmD Case MGMT PCP Nurse Triage APRN Patient Example 1 -SS, 80 yo pt called clinic -C/O hyperglycemia -SMBG log collected

32. Patient PharmD Case MGMT PCP Nurse Triage APRN Patient Example 1 -PharmD notified -Patient called -Insulin adjusted -PCP alerted

33. Patient PharmD Case MGMT PCP Nurse Triage APRN Patient Example 1 -PharmD f/u -Insulin adjusted again -PCP alerted

34. Patient PharmD Case MGMT PCP Nurse Triage APRN Patient Example 2 -89 yo pt called with left knee bump/pain -NT scheduled patient with APRN for acute

35. Patient PharmD Case MGMT PCP Nurse Triage APRN Patient Example 2 -Pain evaluation -PCP consulted -Prednisone + diclofenac gel

36. Patient PharmD Case MGMT PCP Nurse Triage APRN Patient Example 2 -1 week f/u -Patient doing much better -BTW I take too many meds

37. Patient PharmD Case MGMT PCP Nurse Triage APRN Patient Example 2 -PharmD consulted -Phone call with pt -Med review -Found several meds to to stop/switch

38. Results 14 Enrollees 180 Min/mont h 79 Min/ 1 st month 7 saves Age Range: 34-92 Gender: 9 Female, 5 Male 2 Spouse Pairs Enrolled

39. Assume… Patient Panel =2000 patients 20% Medicare = 400 patients Annual Well Visits 80% or 320 patients @ $150 each $48,000 Transitional Care 1 per week @ $120 each $ 6480 Chronic Care Management RN, 100 patients @ $332 per year 1 $33,200 Total Revenue$87,680 1 Ann Int Med 2015, Basu S et al Medicare Payment for Care Coordination

40. Session Outline Background The Rule CCM at WVU Team Dynamic/Re sults Summary/N ext Steps

41. Summary To provide the patient with a well-organized, proactive team connected to a trusted primary care provider to provide more effective care coordination and self-care support May be used as a means for reimbursement for services already provided Family Medicine at WVU has created a service and is the leader/expert of CCM for WVU Medicine

42. Discussion How could you implement this into your practice? What are common problems among your potential CCM patient panel? What team members will you need? What are potential barriers you will need to overcome?

43. Feedback Please take the time to provide feedback using the online form.

44. References http://www.pyapc.com/white-paper-details-new-medicare-payment- chronic-care-management/http://www.pyapc.com/white-paper-details-new-medicare-payment- chronic-care-management/ http://www.cms.gov/Outreach-and-Education/Medicare-Learning- Network- MLN/MLNProducts/Downloads/ChronicCareManagement.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning- Network- MLN/MLNProducts/Downloads/ChronicCareManagement.pdf Please also see the STFM CPI 2015 digital resource library for supporting documents- (consent, informational handout, sample care plan, CMS FAQ’s)