1. Chronic Care Management (CCM) Questions
What are the benefits of providing chronic care management?
Who is eligible and who can provide CCM services?
Does a FQHC provider have to see the patient to begin CCM services?
Who can provide CCM services?

2. 1. What are the benefits of providing chronic care management?
CCM is an opportunity to improve care and patient satisfaction
CCM is person-centered
CCM requires more centralized management of patient needs and extensive care coordination among practitioners and providers

3. 2. Who is eligible and who can provide CCM services?
Eligible beneficiaries have:
‒ Two or more chronic conditions expected to last at least 12 months or until death, that place them at significant risk of death, acute exacerbation, or functional decline
Eligible reporting practitioners/providers:
‒ Physicians, Physician Assistants, Clinical Nurse Specialists, Nurse Practitioners, and Certified Nurse Midwives
‒ RHCs and FQHCs
CCM Services Fact Sheet December

4. 3. Does a FQHC provider have to see the patient?
For new patients or patients not seen within the last year:
Prior to performing CCM services, the provider must furnish a face-to-face comprehensive E&M visit, Annual Wellness Visit, or Initial Preventive Physical Examination, the patient must be properly informed about the nature of CCM services (including how to revoke the service if desired) and consent must be obtained from the patient and documented in the EMR.
For patients that have been seen within the last year:
*Mrs. Jones, an existing patient, would be a good candidate for CCM services. Mrs. Jones has had an office visit with a FQHC practitioner within the last 365 days, but CCM services were not discussed during that visit. Would Mrs. Jones need to come in and have a face-to-face office visit with a FQHC practitioner to provide the informed consent process so that staff can begin CCM services?
1. In your scenario, Mrs. Jones would not need to come in for a face-to-face visit, but would still need to provide consent to receive CCM services.
2. Consent for CCM can be provided by clinical staff but must be documented in the medical record.
* Summary of conversation between Melanie and the CMS FQHC PPS Team from 8/1- 8/8

5. 4. Who can provide CCM services?
Can clinical staff explain CCM services to the patient and obtain informed consent or does that have to be done by a FQHC practitioner?
Consent for CCM can be provided by clinical staff but must be documented in the medical record. ( CMS FQHC PPS Team). Yes, qualified auxiliary staff (clinicians such as nurses, medical assistants, and others who furnish services incident to a RHC/FQHC visit) who are subject to general supervision requirements can complete the consent process.
Consent for CCM can be provided by clinical staff and documentation of acceptance must exist and include:  cost sharing ($8), that only one physician can bill for CCM, patient may stop the service at any time and whether they accepted or declined services. Consent may be verbal or written but must be documented in the medical record, and includes informing them about: (CCM Services Dec 2016)
availability of CCM services and applicable cost-sharing ($8)
only one practitioner can furnish and be paid for CCM services during a calendar month
- right to stop CCM services at any time (effective at the end of the calendar month)
Once the patient has consented to receive CCM services, can other staff furnish CCM services?
Yes once the patient has consented to receive this service, any RHC/FQHC practitioner (physician, nurse practitioner (NP), physician assistant (PA), certified nurse midwife (CNM), clinical psychologist (CP), or clinical social worker (CSW)), or qualified auxiliary staff (in accordance with the direct supervision requirements) can furnish the CCM services. (CCM Services in FQHCs FAQs 2/19/16)
Definitions: Levels of Supervision General Supervision - means the procedure is furnished under the physician's overall direction and control, but the physician's presence is not required during the performance of the procedure. Under general supervision, the training of the nonphysician personnel who actually perform the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician. Direct Supervision - in the office setting means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean the physician must be present in the room when the procedure is performed. Personal Supervision - means a physician must be in attendance in the room during the performance of the procedure.
CCM Services in FQHCs FAQs 2/19/16
CCM Services December

6. CMS is doing a huge campaign to increase CCM services
CMS is doing a huge campaign to increase CCM services. They have developed a website and materials to assist providers.

7. Additional Note: CCM Services
Q14. Can CCM costs such as software or management oversight be included on the cost report? Yes. Any cost incurred as a result of the provision of RHC and FQHC services, including CCM, is a reportable cost and must be included in the Medicare cost report. CMS will be adding a line to both the RHC (CMS ) and FQHC (CMS ) cost report on Worksheet A to specifically report costs associated with the provision of CCM.
CCM Services in FQHCs FAQs February 19, 2016
CHAPTER 29 INDEPENDENT RURAL HEALTH CLINIC AND FREESTANDING FEDERALLY QUALIFIED HEALTH CENTER COST REPORT FORM CMS
Line This cost center includes the cost related to the structured recording of patient health information, an electronic health care plan addressing all health issues, access to chronic care management (CCM) services, managing care transitions, and coordinating and sharing patient information with practitioners and providers outside the practice. CCM services are reimbursed as an add-on payment based on the Medicare Physician Fee Schedule (MPFS). See 80 FR (November 16, 2015).
This slide is just a reminder that FQHCs should include any CCM costs on the Medicare cost report.

8. Gaston Family Health Services CCM Process
Provider reviews the summary and bills/signs the encounter
Pt is identified as qualified for CCM services during MWV
Pt is educated about CCM services by Care Mgr during MWV
Once billable time is achieved, a summary is sent to the provider
Provider reiterates CCM services during CCM
Gaston Family Health Services CCM Process
Pt messages are sent to the provider for FYI and action (as needed)
Pt is identified as CCM patient in the EMR
This slide was provided to us by Lavondia Alexander, Director of Quality and Clinical Informatics ACO Program Manager Gaston Family Health Services. Lavondia would you like to walk us through your process?
The time spent with the pt, and a pt note is documented in the EMR
Pt is follow up is based on goals set during the CCM
High Risk pt engagement is attempted each month

9. Caswell Family Medical Center
We use eCW and have a timer built into our system.  We have one nurse who is designated to work on CCM. This nurse is responsible for enrolling patients in the program, completing care plans and following up with these patients monthly.  All licensed clinical staff can use the timer when completing non face to face care such as medication refills, reviewing labs, reviewing reports from specialists, referral tracking, answering telephone messages, etc.   If someone forgets to use the timer the time can be manually added as well.
The care plans are completed at either an office visit or something over the phone.
Patricia Towler, Clinical Operations Manager, Caswell Family Medical Center. Lavondia would you like to walk us through your process?