Welcome!FQHC Webinar Series Part 1 – Telehealth and Chronic Care Management

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FQHC Series

This is only Part 1 of 3 in the NCTRC FQHC Webinar Series. Subscribe to our newsletter for more information.

Upcoming Topics:

• Substance Use Disorder (Date TBD)• Telemental and Behavioral Health (Date TBD)

RICHARD ALBRECHTDirector, Telehealth Network

Health Network HoldingsWallingford, CT

HOWARD CHAPMAN, JR.Director of Programs and

DevelopmentTri-Area Community Health

Laurel Fork, VA

KATHY WIBBERLYDirector

Mid-Atlantic Telehealth Resource Center

Charlottesville, VA

Presenters

Telehealth &

Chronic Care

ManagementServing Delaware, Kentucky, Maryland, New Jersey, North

Carolina, Pennsylvania, Virginia, Washington DC and West Virginia

NCTRC FQHC

Webinar Series

May 1, 2019

Medicare

What Is It?

Care coordination that is outside of the regular

office visit for patients with multiple (two or more)

chronic conditions expected to last at least 12

months or until the death of the patient, and

that place the patient at significant risk of death,

acute exacerbation or decompensation, or

functional decline. It can be delivered to people

with many different types of health conditions.

Medicare

Requirements

Summary Slide Courtesy of Shannon Chambers

Medicare

CPT Codes

• CCM:

– CPT 99490 (Began January 2017): CCM services, 20 minutes or more of clinical staff time directed by a physician or other qualified health care professional, per calendar month.

– G05011 (Began January 2018): CCM services can be billed by adding the general care management G code to a claim, either alone or with other payable services

– CPT 99484 (Began January 2018) – 20 minutes or more of general behavioral health integration services

– CPT 99491 (Began January 2019): CCM services, 30 minutes or more

• Complex CCM:

– CPT 99487: CCM services, 60 minutes or more with moderate or high complexity medical decision making.

– CPT 99489: Each additional 30 minutes of clinical staff time per calendar month.

CCM

Medicare

• CPT code 99453: Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment.

• CPT code 99454: Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days.

• CPT code 99457: Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month.

– CMS is in the process of writing a technical correction so that the supervision level will be general supervision vs. direct supervision (incident to billing means direct supervision and requires the practitioner and clinical staff to be co-located)

Telehealth & CCM

Medicare

Services furnished remotely using communications

technology are not considered “Medicare telehealth services” and are not subject to the restrictions articulated in

section 1834(m) of the Act. ~ CMS, Federal Register,

November 1, 2018.

• Brief Communication Technology-based Service (Virtual

Check-In) – G2012

• Remote Evaluation of Pre-Recorded Patient Information

– G2010

Telehealth & CCM

Medicare

G0071 (Virtual Communication Services) either alone or with other payable services

• Not originating from a related E/M service provided within the previous 7 days

• Not leading to an E/M service or procedure within the next 24 hours or soonest available appointment

• Involves at least 5 minutes of medical discussion/remote evaluation by an FQHC practitioner

• Only for established patients who have had a billable visit within the previous year

• Must be initiated by the patient via phone, audio/video system or store and forward method (e.g., sending a picture or video for evaluation)

• FQHC practitioner may respond by phone, audio/video system, secure text messaging/email or patient portal

• Must have verbal consent of patient

• Patient will be responsible for any coinsurance

• No frequency limitations at this time

Telehealth & CCM

Medicare

Resources

• Connected Care Toolkit: Chronic Care Management

Resources for Health Care Professionals and Communities:

https://tinyurl.com/yxff5pc9

• Medicare Benefit Policy Manual: Chapter 13 – RHC and

FQHC Services Update: https://tinyurl.com/y4bmgvhc

• Care Management Services in RHCs and FQHCs –

Frequently Asked Questions: https://tinyurl.com/y4apcs9p

• Virtual Communication Services in RHCs and FQHCs –

Frequently Asked Questions: https://tinyurl.com/y22q3lm5

• Comparative Effectiveness Review - Telehealth for Acute

and Chronic Care Consultations:

https://tinyurl.com/y35k2rss

Contact

For More Information:

www.facebook.com/MATRC

www.MATRC.org

National Consortium of

Telehealth Resource Centers

Telehealth & Chronic Care

Management

Howard Chapman, Jr.

Director of Programs and Development

May 1, 2019

• Is a small three-site FQHC serving Carroll, Floyd, Franklin, and Patrick Counties in the Blue Ridge Mountains of Southwest of Virginia

• Tri-Area has two full-service retail pharmacies• It is part of the economically depressed Appalachian

Region• We serve around 10,000 patients with around 35,000

patient visits per year• Around 95 employees and 18 medical and behavioral

health providers• Tri-Area is NCQA Level III Recognized as a Patient

Centered Medical Home

Policies and Issues Affecting Telehealth

• Begin using Telemedicine/Telehealth in 2000

• We started with the UVA Office of Telemedicine

Access to 24 separate specialties

As a state supported medical school, UVA

provided services on a Sliding Fee Scale basis

We begin with an “incident to” consult code

(CMS stopped recognizing the code in 2005-2006)

Virginia Telemedicine Regulations

• Parity Law mandates equivalent coverage for telemedicine and in-person services from private payers, Medicaid, and state employee health plans

• State mandates reimbursement only on medical services provided via live video and provide limited coverage for other telehealth applications

• Tri-Area is paid for telemedicine services, even as a Distant Site by Medicaid and most commercial insurance

Issues

• Poor Connectivity and Broadband in rural Southwest Virginia

• Currently 50 mbs Laurel Fork site and 20 mbs at other sites and Corporate Office

• 2 Years ago 10 mbs Laurel Fork site, 6 mbs Floyd site, and 3 mbs Ferrum site and Corporate Office

• Competing with EMR, Practice Management System, email, and internet for bandwidth

Human and Technology Resources Required for Telehealth

• Camera, Monitor, Cart Set-Up Under $12,000 (18 years ago around $75,000)

• Good Connectivity (25 mbs or greater)

• Secure Network to maintain HIPAA Requirements

• Trained Staff (Certification Programs like STAR, UVA has a Certification Program)

• Provider Champion and support from Senior Management

Benefits to Community Health Centers

• Removes rural isolation for physicians and makes it easier to recruit and retain

• Compliance with Patient Centered Medical Home

• Improved Patient access to specialty care

• Improved Patient Compliance with Treatment Plans

• Improved Coordination of Care

Types of Telemedicine/Telehealth Used

Synchronous (live/real-time)

• Access to 24 Specialties through UVA

• UVA has a sliding fee program for our Virginia uninsured patients

• Provider and Staff CME

• Patient Education (Certified Diabetes Education Classes)

• Diabetes Quality Improvement Plan

Asynchronous (Store and Forward)

• X-Ray Interpretation through UVA Transferred electronically

Results the next day

STAT readings in emergencies

• Digital Retinopathy Screening Diabetic Screens for Patients

(40% reported first screening they had)

FDA approval for iPad and smart phone to get results within 20 minutes

• Cardiology

• Dermatology

• Endocrinology

• ENT

• Gastroenterology

• Gerontology

• Gynecology

• Hematology

• Hepatology

• Infectious Disease

• Nephrology

• Neurology

• Ophthalmology

• Orthopedics

• Pain Management

• Pediatrics

• Pediatric Cardiology

• Plastic Surgery

• Psychiatry

• Pulmonology

• Rheumatology

• Surgery

• TCV

• Urology

Diabetes Quality Improvement Program

• Focus on uncontrolled Diabetic Patients HbA1c of 8 or higher

• Endocrinologist follows them for 6 months with telemedicine and on-site at Tri-Area

• Coupled with the Certified Diabetes Education Classes and the Diabetic Retinopathy Screenings

• Uses home monitor to measure blood glucose, dietary intake, physical activity etc.

• Uploaded to smart phone and to a secure cloud server when the patient reaches Wi-Fi signal (not real-time)

• Graphs the data and can be accessed by the endocrinologist, the patient, Tri-Area providers, nurses, and case managers with secure password clearance

Two year data telemedicine diabetes

9.9±1.6 7.7±1.1

N=30

Design Interventions

Intense six month Self-Management component

Use of Project ECHO Educational Programs

Technology Components

Use of meal replacements

Cloud based Telcare meters

Glucomander-outpatient algorithmic insulin

decision making program

Deliverables of Program

• Reduction in glucose levels assessed by HbA1c

• Number of pounds and body weight loss

• Improvement in knowledge regarding diabetes based on pre- and post- testing questionnaire

• Absolute drop in blood pressure

• Improvement in the level of exercise

Problems

• Non-Compliance with number of glucose test requested per day

• Non-Compliance with diet

• Lack of motivation for better control

• Limitation of medications used based on financial situation

• Undercurrent Illness (UTI, URI, etc.)

Solutions

• Telephone Calls from Dr. Santen or the nurses encouraging proper testing (strips and Meter are at no cost to Patient)

• Nutrisystem D meal replacement (3 meals per day at no cost to the patient)

• Behavioral health consults and Diabetes Support Group with family members participation

• Medication Assistance Program, plus 340-B medications

• Prompt treatment by Tri-Area providers for undercurrent illness

Telehealth Resource Centers Thank You!

• Telehealth Resource Centers are an excellent resource for providing education to organizations and individuals interested in telemedicine/telehealth and other health technologies

• They link interested providers, health facilities, and programs to successful programs that are using telemedicine

• They provide technical assistance and arrange trainings to get programs up an running

Thank You! / Questions?

Contact Information:

Howard Chapman, Jr.

Director of Programs and Development Tri-Area Community Health

14168 Danville Pike / P. O. Box 9

Laurel Fork, VA 24352

Telephone: 276-398-2292 ext. 2221

Cell: 276-494-1143

Email: hchapman@triarea.org

Chronic Care Management for FQHCs(And What We’ve Learned Over the Past 2 Years)

May 1, 2019

Our Agenda Today

• Who We Are

• Why We Were Interested

• Our Decision Process

• How We Implemented

• Lessons and Results

Health Network Holdings Inc. 35

What and Where is “Health Network Holdings”?

Why We Were Interested

Health Network Holdings Inc. 37

How CCM Benefits the Patient

Health Network Holdings Inc. 38

A regular check-in call by theirown care manager to assistwith any needs, provide coaching and support, and who will update the patient’s care team with any changes or concerns.

An up-to-date Care Plan with their current health goals.

How CCM Benefits Health Centers

Health Network Holdings Inc. 39

Clinical teams stay better connected with chronically ill patients.

Centers receive reimbursement for documented non-face-to-face care coordination activities.

Aligned with Our Strategic Goals

• More resources and outreach for patients who most need it

• Positive reimbursement for services already being provided

• Fully aligned with PCMH

Health Network Holdings Inc. 40

Our Decision Process

Health Network Holdings Inc. 41

Assessing the Opportunity / Cost

Health Network Holdings Inc. 42

General Chronic Care Management Financial Projections

2019 G0511 Rate: 67.03$ Actual net reimb.pp/pm $50.00

0.7 0.5 0.75 $67.03 75%

Estimated Number

of Medicare Pts.

Assume 75% of

patients with 2+

chronic

conditions

Assume 50%

Adoption Rate

Assume 75% of

patients meet the

monthly service

requirements

Potential

Monthly

Revenue

Potential Annual

Revenue

Assumed Annual

Cost of providing

CCM @ $50 per

billable patient

1,200 900 450 335 22,455$ 269,460$ 201,000$

CMS Requirements for CCM

Health Network Holdings Inc.43

Patient Provider

2 or more chronic conditions

Must use a certified EHRtechnology

24/7 access to care team for urgent needs

Serious health risk 20 minutes per patient per month of care coordination services

Care plan is updated as needed to remain current

Must consent to receive services, and consent is documented

Qualifying activity time must be documented: date, staff, description

Continuity of care with care team for successive routine appointments

May only consent with one provider at a time

Comprehensive patient-centered care plan congruent with patient’s goals and values

Care plan is created and managed within a technology platform

May have a co-pay Shared with patient Service period is one calendar month

The Next Most Important Questions

1. Does our organization have the capacity to take it on?

2. Do we have a senior clinical manager or team to lead it?

Health Network Holdings Inc. 44

• How to identify eligible patients and track enrollment requirements?

• How to create the protocols and processes for following up with patients with various chronic conditions?

• How to compliantly and efficiently manage and document services provided for 100s of patients?

CCM Implementation Challenges

• Who is going to train and manage the staff to enroll patients, create care plans and deliver services efficiently?

• Who will cover for sick days, vacation time, turnover, etc?

• Who is going to monitor patients in the program to ensure that enrolled patients receive the full scope of services?

DOCUMENTATION & TIME MGMT STAFFING & RESOURCES TO EXECUTE

Processes, Technology and Staff to Meet the CMS Requirements

Health Network Holdings Inc. 45

Option: Partner with an Experienced CCM Vendor

Do Everything with Internal Staff Work with an External Partner

The best option if you have sufficient clinical staff and good management resources to dedicate to CCM

No need to hire and train additional staff

Easier to integrate some activities within EMR Less internal effort and faster time to launch

Need to have a system to track time and activities Service partner is 100% focused on results

Greater control of day-to-day activity No need to create protocols, scripts and templates

Communication within the practice may be better Less time required to manage staff

Patients may appreciate interacting with local staff Program continuity likely to be better

Likely to have greater number of sustained patients

No up-front investment: cost is performance based

Health Network Holdings Inc. 46

Evaluating CCM Service Vendors

Health Network Holdings Inc. 47

Vendor A Vendor B Vendor C Vendor D

Vendor E

1. How long have you been providing CCM Services?

Since Jan. 2015 Since July 2015 Since 2015 Since 2015 Since Sept 2017, subcontracting portions to a 3

rd party vendor “Citra”

2. How many clients do you have? In how many states do you work?

300 locations/ 35 states 39 Clients in 19 states 54 clients in 28 states 40 clients are Greenway

2 clients in CT Would not disclose; Have clients in 9 states

3. How many employees in your organization are devoted to CCM?

270 24 35, with 6 outsourced software developers

8 Citra has over 100

4. Is there a minimum # of eligible patients you require a client to have? If so, what is it?

No minimum 200 eligible 2,000 eligible No Minimum 36 active patients

5. What is your average enrollment rate of eligible patients?

40% of eligible using remote enrollment program

50%-70% of eligible 30-50% of eligible within 12 months, but depends on practice staff buy-in

Over 60% Quest does not enroll patients Require client to complete a referral form and send it to Quest for each patient

6. How many patients do you have under active management (enrolled patients)?

Nearly 40,000 Approx. 8,000 – 40% of clients just using software

10,000 Implementing 2 clients with 40,000 CCM eligible patients

Would not disclose

7. How many FQHCs do you work with?

10 6 2 1 – Community Health and Wellness, Torrington, CT

2

8. For how long have you been working with FQHCs?

January 2017 Since November 2016 3 months 1 year A few months for CCM

9. What is the biggest challenge you have found in working with FQHCs?

Educating staff how to work with an external partner

Developing workflows that fit within the FQHC environment

Competing with other priorities to get staff aligned to launch program

Have developed tools & processes to help with this

Which pts are dual eligible

Patient enrollment

Provider buy-in and support

Maintaining patient engagement

Patients with co-payments

10. What percent of 99.5% 74% for clients using our 95% Over 50% of enrolled >95%

How We Implemented

Health Network Holdings Inc. 48

Our Implementation Models

Health Network Holdings Inc. 49

CCM Implementation Sequence

• A Structured Process

• Commitment

• Weekly Calls/Meetings

Health Network Holdings Inc. 50

Establish Project Timeline

Develop Protocols

Identify Eligible Patients

Inform and Enroll Patients

Create Care Plans

Deliver Services and Document Time

Submit Billing for Services

First 1-2 months

Explain program & obtain

patient consent

Create CCM care plan & share with

patient

StaffDocument Qualifying Activities

PATIENT ONBOARDING ONGOING, MONTHLY

Health Network Holdings Inc. 51

What to Expect

1. By Mail: Typical patient information sheet mailed to CCM-eligible patients.

This was printed in Spanish on the reverse side.

2. At the next scheduled office visit.

Health Network Holdings Inc. 52

Informing Eligible Patients

Monthly Care Outreach Activities

Health Network Holdings Inc. 53

Patient Centered Care Plan Care Plan reviewed and utilized as guide for discussions with patients and updated with any relevant changes.

Medication Oversight Medication reconciliation, treatment adherence, & prescription renewal assistance

Monitoring & Assessment Ongoing monitoring and assessment of patients medical, functional, and psychosocial needs, in accordance with Care Plan

Appointments & Community Services

Help patients schedule and attend appointments. Assist with barriers and follow up after appointments; Coordinate with community and home based services

NotifyNotify providers and nurses of any changes or updates with the patients’ health

Lessons and Results

Health Network Holdings Inc. 54

Five Key Lessons

Health Network Holdings Inc. 55

1. Buy-In: Providers must understand and support the program, and all staff

members must understand the value of CCM for patients, and how to

discuss it with patients.

2. Project Management: Strong project management of all aspects of the

process generates far better results for patients and the program.

3. Dedicated Staff: Dedicate staff to this program. Existing staff have other

responsibilities, and cannot always allocate the time to CCM that it

requires. Typical results when staff are not dedicated:1. Fewer patients get enrolled

2. Too many patients don’t receive services consistently, or with good quality

3. Patient attrition is high, as they don’t see value in the program

4. Start Small: Begin at one site, or with a manageable number of patients.

5. Goals: Set monthly/quarterly goals and manage to them.

Results to Date

• Over 2,500 patients receiving CCM services

• Incredible anecdotes from patients and care managers– Helped a patient keep her housing

– Improving medication management, refills and adherence

– Appointment assistance (PCP visits up 11%)

– Arranging for social services

– Improved continuity in patient record

– Patient engagement in health goals

• Phase 2– Assisting with AWVs

– Targeted preventative screenings for quality measurements

– Care transition follow-up

Health Network Holdings Inc. 56

Questions & Discussion

Health Network Holdings Inc. 57

Richard Albrechtralbrecht@chnct.org

Office: (203)949-4032Mobile: (860)810-8599

linkedin.com/in/ralbrecht08

Thank you!

Look out for more information on Part 2 of our FQHC Webinar Series.

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58

Kathy Hsu Wibberly, PhD

Director, Mid-Atlantic

Telehealth Resource Center

UVA Center for Telehealth

Email: Kathy.Wibberly@virginia.edu

Phone: (434) 906-4960

Richard Albrecht

Director, Telehealth

Network, Health Network

Holdings, Inc.

Email: ralbrecht@chnct.org

Office: (203) 949-4032

Mobile: (860) 810-8599

Howard Chapman, Jr.

Director of Programs and

Development

Email:

hchapman@triarea.org

Telephone: (276) 398-2292

ext. 2221

Cell: (276) 494-1143