1. Benefits of Care Management
Presented By:
Keisha Sexton, BBA; Office Manager
Natalie Harter, LMSW; Complex Care Manager
Mitzie Hewitt, DO; Medical Director & Clinic Owner

2. Disclosure
The content of this presentation does not relate to any product of a commercial interest. Therefore, there are no relevant financial relationships to disclose.

3. Northern Pines Health Center, P. C
Northern Pines Health Center, P.C. “Northern Pines Health Center is committed to compassionate, high quality healthcare, while stressing prevention and health education for patients of all ages.”
Northern Pines Health Center is an independent rural health clinic located in Buckley, MI. The clinic offers primary care services to patients of all ages delivered by a healthcare team comprised of: a Physician, Physician Assistant, Nurse Practitioner, Care Manager and 13 administrative and clinical support staff members.

4. Objectives Define Care Management & its purpose.
Identify patients who can benefit from Care Management.
Identify sources of reimbursement for Care Management services.
Discuss the Care Manager’s role & responsibilities.
Learn about the benefits of Care Management from a Provider’s perspective.

5. What is Care Management?
Care management is a set of activities designed to assist patients and their support systems in managing medical conditions and related psychosocial problems more effectively, with the aims of improving patients’ functional health status, enhancing the coordination of care, eliminating the duplication of services, and reducing the need for expensive medical services.
Bodenheimer T, Berry-Millett R: Follow the money - Controlling expenditures by improving care for patients needing costly services. New Engl J Med 2009;361(16):

6. Who can benefit from Care Management?
Patients who have a new diagnosis of a serious health condition.
Patients with multiple chronic conditions such as COPD, Diabetes, Cardiovascular Disease or Asthma.
Patients with uncontrolled chronic conditions such as Hypertension or Diabetes.
Patients with recent and/or frequent hospital admissions, ER or Urgent Care visits.
Patients who struggle with issues related to social determinants of health.

7. Reimbursement for Care Management Services

8. State Innovation Model (SIM)
Medicaid Patients
Monthly Patient Lists
Specified Care Management Codes
Required benchmarks must be met for specified metrics
Quarterly payments based upon SIM targeted population
State Innovation Model (SIM)

9. Provider Delivered Care Management (PDCM)
Blue Cross Blue Shield
Monthly Patient Lists
Paid on claims for specified codes
Incentive payments if metric benchmarks are met
Provider Delivered Care Management (PDCM)

10. Priority Health Priority Health Commercial High-Utilizer reports
Paid on claims for specified codes
Incentive payments if metric benchmarks are met
Priority Health

11. Chronic Care Management (CCM)
Medicare
Specific patient eligibility requirements:
(Multiple (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
G0511 (paid in addition to the billable rate)
2018 payment (HCPCS code G0511) – $62.28
Chronic Care Management (CCM)

12. Care Manager’s Role & Responsibilities

13. Care Manager’s Role Provide Health Education
Manage Health Problems with Goals to Feel Better
Help with Transportation
Coordination of Health Care Services
Answer Questions
Provide Connections to Community Resources
Locate Resources for Housing, Food and Utility Assistance
Assist with Medication Management
Assist with Advanced Directives
Assist with Insurance Coverage

14. Incorporating Care Management in Your Rural Health Clinic
A Provider’s Perspective

15. Benefits of a Care Manager in the Clinical Setting
Providing education and training for patients.
Expert in community resources.
Identifying obstacles that interfere in patients getting to identified goal.
Closing Gaps of care.
Great point of contact for patients needing assistance.
Billable codes that can help generate additional funding for the clinic.
Improve overall patient satisfaction.

16. How Patients are Identified for Care Management
Provider schedules are reviewed by the Care Manager 1-2 days before to identify patients that qualify for CM.
Providers identify needs of a patient during the office visit.
Reports are run for specific gaps of care with patient groups that qualify for care management.
Reports are run for specific groups of patients that qualify for care management.

17. The Financial Impact of Having a Care Manager
Billable codes that are payed to the Rural Health Clinic.
Priority Health commercial / Priority Health Medicare
Blue Cross Blue Shield
All Medicare (chronic care management)
Medicaid (SIM)
Increased revenues by closing care gaps.
When providers bill for services to close gaps in medically necessary care, more revenues are captured.
As care gaps are closed, performance in governmental programs (HEDIS, PCMH, MACRA) and commercial (pay-for performance) contracts are improved and in turn, fee schedules are increased.

18. Improved Quality of Care for our Patients
As providers we want to do a better job of educating our patients but have multiple barriers.
TIME!!
Financial constraints (especially in Rural Health Clinics)
Patients not admitting barriers.

19. Questions?

20. Resources:
Visit the following resources to learn more about the information discussed in this presentation:
Michigan Care Management Resource Center:
State Innovation Model (SIM):
Provider Delivered Care Management (PDCM): group-incentive-prog/models-of-care/provider-delivered-care-management.html
Priority Health:
Care Management Services in Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) FAQ:
Northern Pines Health Center, P.C.: