Tripp Bradd, MDJan Bradd, RN, BSNAugust 2015

PPRNET WorkshopCharleston, SCAugust 27, 2015

IntroductionsTripp Bradd, MD, FAAFP

President / Physician of Skyline Family PracticeMember of PPRNET advisory board

Jan Bradd, RN, BSNNurse Manager / VP of Skyline Family Practice

Skyline Family Practice(the near future)

Goals

This workshop will endeavor to:

• Explain the actual benefit by CMS.• How Skyline FP (and Lovelace FM_ setup up

to do Chronic Care Management (CCM).• Provide ideas and resources for further

reading and reference but most importantly … action!

World of CCM

IntroductIon

FAQ’s

cMS regS

cloSIng coMMentSAnd Q&A

chAllengeS

Setup

Chronic care management is really good news for medical practices!This benefit for Medicare beneficiaries is ALSO a benefit for clinicians and medical practices.

Chronic Care Management – part of primary care

We’ve been doing this all along in primary care haven’t we?

• Medication Reconciliation• Medication Management (refills, etc)• Forms (DME, DMV, etc)• Coordination of Care (Referrals – consultants/home health/PT/OT)• Transitions across care domains (Hospital<->ER <->Office <->Home)• Health Maintenance and its coordination• A lot of out of office care for patients in general…Also…• You may have even been involved with various quality initiatives to

improve care through the years.

Chronic Care Management – the new benefit

On November 13, 2014, the Centers for Medicare and Medicaid Services (CMS) issued the Medicare Physician Fee Schedule final rule, including a new code and guidance for billing for chronic care management services (CCM), effective January 1, 2015.Medicare patients can get what many practices have been doing all along:

Chronic Care Management (of chronic diseases)And…Practices can get paid for doing the work.*

*Isn’t that NICE?

What? Chronic Care Management!!

!As if I didn’t have

enough to do withmeaningful use, PQRS,

PCMH, ACO’s, etc. There’s No time and …

NO MORE ENERGY!This is a typical reaction, whenanother government initiative, like Chronic Care Management, is proffered to a clinician or medical practice.

But . . . the newsis more positive thanthis clinician understands.

Wow! CCM seems like a lot of work?....

I hear common comments from you like:

“My plate is already too full!”

“We are overwhelmed!”

“Our staff can’t work any harder!”

YES we are ALL “overwhelmed”!

You are well positioned to really benefit from this program!

Why?

1. You are watching the webinar and/or are attending the user group meeting!

The first step is interest in doing something or doing something better isn’t it?

2. We are blessed with a certified EHR that does offer process paths to getting CCM done

3. We are part of a community of users who get efficiency, quality and process AND more importantly, are willing to share!

Nibble each day….

Slowly and progressively work on your processes --- each day and each week.

Sooner than you realize, you’ll have things in place. Once you’ve spent time with staff, they’ll ‘automate’ the steps and your Chronic Care Management system will work -- We’ll talk about the NEW REALITY concept.

IF WE CAN DO IT – “YOU CAN DO IT”

For us, the time to implement CCM, from concept to initial operations, was about 2 months but you may be able to do it more quickly.

We are still refining our processes and efficiencies. We use the PDSA (Plan-Do-Study-Act) cycle* to continue to get better!

by J. Toussaint, MD and R.A. Gerard, PhD.*A good and readable book: “On the Mend – Revolutionizing Healthcare to Save Lives and Transform the Industry”

SFP Mission Statement

Offer our patients the best care using the most up-to-date knowledge and information systems

And…to be a profitable business.

morning

ScheduledPatient

CareTime

ScheduledPatient

CareTime

“Breaks”between

direct patient

care

“Breaks”between

direct patient

care

Catch up

Catch up

Catch up

TYPICALMEDICALOFFICE

DAY(Clinician’s

Perspective)

Fulfilling our mission

How can we usethat “ketchup” timein the most efficient waysto fulfill our mission statement?

Capture that “ketchup” timeand bill for it!

MAYBE NOT CAPTUREour “KETCHUP” TIME

this way!

morning

ScheduledPatient

CareTime

ScheduledPatient

CareTime

“Breaks”between

direct patient

care

“Breaks”between

direct patient

care

Catch up

Catch up

Catch up

Chronic Care

ManagementOpportunities

Chronic Care Management

What has CMS proposed and now provided?

Chronic Care Management – General points

Overall Points Consent needed from each patient before CCM can occur Need to use a certified EMR Care of the patient is with the patient out of the office Patients need a discrete ‘written’ care plan Patients will need electronic access to this care plan

CCM has to total 20 minutes per month Billable at $42.60 per patient per month (patient will have 20% co-pay)

Can still see the patient in the office (and bill) during this time

Chronic Care Management

1 - Structured recording of demographics, problems, medications,medication allergies, and the creation of a structured clinicalsummary record. A full list of problems, medications andmedication allergies in the EHR for the care plan, carecoordination and ongoing clinical care.

What follows are essential 12 points of CCM.

Chronic Care Management

2 - Access to care management services 24/7 (providing thebeneficiary with a means to make timely contact with health careproviders in the practice to address his or her urgent chronic careneeds regardless of the time of day or day of the week).

Chronic Care Management

3 - Continuity of care with a designated practitioner or member of thecare team with whom the beneficiary is able to get successiveroutine appointments.

Chronic Care Management

4 - Care management for chronic conditions including systematicassessment of the beneficiary’s medical, functional, andpsychosocial needs; system-based approaches to ensure timelyreceipt of all recommended preventive care services; medicationreconciliation with review of adherence and potential interactions;and oversight of beneficiary self-management of medications.

Chronic Care Management

5 - Creation of a patient-centered care plan based on a physical,mental, cognitive, psychosocial, functional and environmental(re)assessment and an inventory of resources and supports; acomprehensive care plan for all health issues. Share the care planas appropriate with other practitioners and providers.

Chronic Care Management

6 - Provide the beneficiary with a written or electronic copy of the careplan and document its provision in the electronic medical record.

Chronic Care Management

7 - Management of care transitions between and among health careproviders and settings, including referrals to other clinicians;follow-up after an emergency department visit; and follow-up afterdischarges from hospitals, skilled nursing facilities or other healthcare facilities.

Chronic Care Management

8 - Coordination with home and community based clinical serviceproviders.

Chronic Care Management

9 - Enhanced opportunities for the beneficiary and any caregiver tocommunicate with the practitioner regarding the beneficiary’s carethrough not only telephone access, but also through the use ofsecure messaging, internet or other asynchronous non face-to-faceconsultation methods.

Chronic Care Management

10 - Beneficiary consent - Inform the beneficiary of the availability ofCCM services and obtain his or her written agreement to have theservices provided, including authorization for the electroniccommunication of his or her medical information with othertreating providers. Document in the beneficiary’s medical recordthat all of the CCM services were explained and offered, and notethe beneficiary’s decision to accept or decline these services.

Chronic Care Management

11 - Beneficiary consent - Inform the beneficiary of the right to stop theCCM services at any time (effective at the end of the calendarmonth) and the effect of a revocation of the agreement on CCMservices.

Chronic Care Management

12 - Beneficiary consent - Inform the beneficiary that only onepractitioner can furnish and be paid for these services during acalendar month.

FAQ’s regarding CCM

Q: What is that CPT code again?A:

Allowables and deductibles:

Q: How much does Medicare allow for this service? A: The Medicare allowance will vary geographically. However, the geographically unadjusted amount is approximately $42 per month.

Q: Are CCM services subject to Medicare’s deductible and coinsurance? A: Yes

For us (6/2015)Medicare reimbursement is $33.13 plus patient co-pay of $8.45 = $41.58

Need an AWV?

Q: Must a patient have received a Medicare annual wellness visit (AWV) in the past 12 months for a provider to be able to bill separately for CCM services? A: No. While CMS proposed to make this a requirement at one point, it now simply recommends, but does not require, a provider to furnish an AWV or initial preventive physical examination (IPPE, also known as a “Welcome to Medicare” visit) to a patient before billing for CCM services furnished to that same patient.

Please note however that to initiate Chronic Care Management you will need to have a ‘face-to-face’ with the patient. That would happen through an E&M visit (Evaluation and management office visit), a AWV or IPPE (Initial preventative physical examination).

Medicare Advantage Programs?Q: Will CCM work with Medicare Advantage programs? A: Good question – We have Humana patients and we’ve asked that question*. Waiting for a response from them but we** see no reason NOT to let our Humana patients (a group of patients in our practice) who use the Humana Medicare Advantage program benefit from this service. (so see below – it appears so …)

*asked this question 1/15/15 – they will “get back with us”

Response 1/23/15 follows:

**”we” meaning Skyline Family Practice

“…This is a new code as you mentioned effective 1/1/2015 that CMS has recently approved for payment. Humana, like most Medicare Advantage companies follow CMS guidelines. While Humana cannot guide on billing, you can certainly check out various website surrounding this new code on billing guidelines/requirements.Thank you,Maria G. Bryan, CPCProvider Relations Consultant/ MSO Operation …”

Humana reimbursement is $27.91 with $20.00 patient co-pay = $48.00 (varies)

ACO’s?

Q: Can Medicare shared savings plans (i.e., Medicare accountable care organizations) bill for this service? A: CMS has not excluded these plans from billing this service*.

*However, in my humble opinion, you want the primary care offices doing this since they are actually doing the work and any work that is done is “rewarded” to those doing the work.

MAPCPD or CPCI?

Q: Can I bill CCM services if I am participating in Medicare’s Multi-Payer Advanced Primary Care Practice Demonstration (MAPCPD) or the Comprehensive Primary Care Initiative (CPCI)? A: If you participate in either MAPCPD or CPCI, you may NOT bill Medicare for CCM services furnished to any patient attributed to your practice for purposes of participating in one of these initiatives. However, you may bill Medicare for CCM services furnished to eligible patients who are not attributed to your practice as part of these initiatives.

FQHCs and RHCs?

Q: Are federally qualified health centers (FQHCs) and rural health clinics (RHCs) excluded from billing this service? A: This is not yet known. The American Academy of Family Physicians has strongly urged CMS to include a mechanism for RHCs and FQHCs to bill for CCM services, especially since CMS allows RHCs and FQHCs to bill the TCM service.

(Note: in a communique by me with CMS – preliminary query would indicate NO – not at this time.)

Excluded CPT codes and G codes?

Q: May I bill Medicare for CCM and transitional care management (TCM) services provided to the same beneficiary during the same time period? A: No. You cannot bill CCM services for a patient during the same 30-day period in which you are otherwise billing Medicare for

• TCM services (99495 [$126.51 at SFP] or 99496), • Home health care supervision (G0181), • Hospice care supervision (G0182), or certain end-stage renal disease services

(90951-90970). • Remote patient monitoring services (99090) – recently added

*Will still track CCM in a “TCM Services” month in case the TCM reimbursement fails.

Allowed CPT and G codes

Allowed -99091 May be added to the CCM time

(From AMA CPT site – 99091 - Collection and interpretation of physiologic data (eg, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time) – but it can’t be the only “CCM” work done!

G0180 ($41.70 for SFP) and G0179 – F2F referral for home healthare, so far, not mentioned and therefore are probably allowed.

Is CCM worth doing? (from a business perspective)

YES!

But… there are usually some ‘naysayers’.

Perhaps seeing how this process can help those in your organization see the return on investment may be a ‘tipping point’.

SFP Performance Jan-2 to June 16-2015

• Current SFP patients signed up for Chronic Care Management

• 700 (~ 10 % Humana, Rest – Standard MCR)

• All Opting in except for:• “Frank” opt out 4 (1 signed back up)• Revocations – 4 – (1 signed back up)

• So 99+% acceptance rate thus far

SFP performance through July 31, 2015

MORE TO COME later!

Other benefits of CCM for you and your practice?

Some benefits for SFP and its patients are listed below:

• “Stop gap” until SFP fully staffed with providers (currently short providers)

• SFP staff can remain busy (staff retention)• Allows SFP to remain a viable business

Other benefits of CCM for you and your practice?

Other benefits for SFP and its patients:• Patients will get improved care

• Increased “touches” with patients (patient better educated / more satisfied?)

• Identifying patient needs before ‘known’• Refilling meds just before needed (less calls to office?)• Patient referred to services before ER or Hospital need?

• Decreased high cost utilization (as a result of “pre-emptive care”)• Staff satisfaction (more involved with direct care and outcome)

• Staff become their own “income stream”• Improved performance with quality measures

• (PPRNET/PQRS/ACO, etc)• U.S. IS MOVING TOWARDS PAY FOR QUALITY

CCM is a prototype for future P4Q programsExpansion of P4Q programs are not a matter of IF but only HOW FAST

Setup*

Working through the steps and processes of getting the EHR to work for you, your staff and for your patients requires some time and energy

*this is for Practice Partner (EHR) but various aspects could be used by any office and their EHR.

SetupOperations Setup• Setup of the software

• Clinical Elements• Registry• Quicktext• Templates

• Notes• Messages – Internal and Webview• ‘On-demand’ quicktext• Care plan

• Knowledge Base - resources• Interaction of all of the above

• Staff education and process flow – “PDSA”

Setup

Patient interfacing processes• Consent form

• Will be on EMR File Sharing• Link to your knowledge base/put on your website

• Care Plan population• Form for “other information”

• Use this to help you get all sorts of info• Contact information (we’ve tried with 3 contacts• Adv. Med. Directive / DPOA• Another chance to get Webview registration (adult child of patient)

• Using IMH to populate information• Webview Setup

• Making care plan accessible – Webview setup• Welcome to CCM message (for care plan)

Create the Clinical Elements

Clinical Elements (also Lab Elements)

• CCM – Participation • CCM – Method to track time• Contact Data – for the Care Plan• Webview• Risk Management

Clinical Elements Using Clinical Elements allows for a way to track process flows and get information to help your “Chronic Care Management Nurse” or team.

Clinical ElementsCreate Contacts so staff won’t have to “chase” down the numbers, etc.Didn’t include emails but that’s another good idea isn’t it?

Additional Clinical Elements will be added as the need arises.

How do I populate the registry?Here is one method using the PPRNET report

You can simply use the CCM sheet in the Patient Level Registry spreadsheet from PPRNET to populate the registry you create. You can do this fairly simply once you understand how to export this sheet and convert it to import into your registry.

The steps to import into your new registry

The link below is a PDF to show you how to setup up your new registry and then import your patient list from the CCM sheet in your PPRNET report.

Import CCMto createa registry

Working the registry – Create a registry

Most EHR’s allow for the creation of a registry of patients. Create a registry for your staff to work with your Chronic Care Management panel of patients. In the above example, the name of this registry (for us) is “CCM”.

Working the registry

Views of different registry elements

Using the Registry in the EHR allows the Nurse to “work the registry” and quicklylink to each patient chart. (also the registry can be exported as a spreadsheet*).

*

Working the registry

Views of different registry elements – cont’d

Putting the pieces together!

Process Flow and Development

www.lucidchart.com

Resources without a plan lead to nowhere!

Putting it all together

Please note: “IMH” is Instant Medical History and currently thereis no process yet developed by Primetime Medical Software

Patient fills out Form On-Line or

In Office(Kindle/Tablet)

Templates• What follows is the template staff are using when they work the registry

to do the various tasks

• The idea here is to use the progress note as the second “platform” from which to work and then “log out” of the work for that patient while collecting the time required to bill for the service (when note is saved.

REGISTRY is the FIRST WORK PLATFORM (all CCM eligible patients)

CONCEPT

Progress note template is the SECOND WORK PLATFORM (to track the work and log the time per patient)We use a Quicktext for “Demand CCM work”*

*You could create Quicktext also which we will probably do also

Quicktext for automating CCM registry buildHere is the logic in the “.MU-Provider” quicktext

||IF PAT_CARRIER1_NAME = "MEDICARE" OR PAT_CARRIER2_NAME = "MEDICARE" OR PAT_CARRIER3_NAME = "MEDICARE" OR PAT_CARRIER4_NAME = "MEDICARE" OR PAT_AGE >= "65"

{NU - show CCM Video if not seen «del» <BR>Print Consent form and give to patient «del» <BR>

«PLINK: CCM CONSENT | P:/ppart/intranet/Skyline_Staff/FORMS/SFP_Consent_Form_CCM.pdf» <BR>

.CE: CCM CONSENT GIVEN: «REQ»«Y or N» <BR>

.AC: FRT Give Consent to ST for scanning --> COPY for patient <BR>

.ARS: CCM}

ELSE{}||

Selection criteria

Selection criteria not met and nothing put in note

Selection criteria met. (by line)1 – Show video2 – Instruction to

print consent3 – Consent link4 – Clinical element

for registry5 – Action for FRONT

staff6 – Pt. added to

registry

Concept is to have a quicktext that staff triggers within each template (or you can add the logic within each template to ‘capture’ most of your eligible patients. Remember, each Medicare patient must have 2 ‘chronic conditions’ to qualify.

Quicktext – Consent given

Added by clinician in a progress note* (or anywhere else) when consent given to patient. This adds patient to the CCM registry (OK if already there). .AC code directs FRONT staff to send the consent to ScanTech. PLINK is Link to consent.

*this is that “face-to-face time” before beginning CCM

Quicktext – for Scantech

Quicktext Added by scantech once consent in chart is in the chart. This helps with tracking process FLOW. “CCM IN OUT” officially allows practice to start CCM. Of course, if patient subsequently ‘revokes’ the agreement, the variable would be “OUT” (create a quicktext for that or enter into Clinical Elements).

CON

TACT

NO

TE Providing the staff member with the information needed and a place to log the contact time

Contact Note – Start time

Time the staff member starts the actual care of the patient is automatically inputted

Contact Note - demographics

Demographics can be quickly checked for accuracy and corrected.The staff person would go to demographics or the clinical elements.

Contact Note – Clinical Info

This portion identifies health maintenance or other quality metrics. Also this section provides clinical information the staff may need for medication reconciliation or other clinical information to know about. All this information is easily brought to the CONTACT NOTE “PLATFORM”.

Contact Note – Care Team

Place for staff to recognize care team members or log them into the EHR. Various codes will be added to automate this even more.

Contact Note – Capturing the time

Concept here is create an easy way to capture the actual time of the contact. You can not ‘round up or down’ the minutes. Saving the note (could‘stamp’ the time at the end of the note) but this would be subject to some inaccuracy.

Start time (automatically placed)

End time for contact. This is a quicktext which is clicked to activate current time of clicking (||TIME||)

Contact this for this encounter(End time minus start time*)

Cumulative time up to this point with date of last entry

New total time that month

Demand CCM Logging -- QuicktextCCM ContactItems dealt with:«*»||IF CE<CCM Consent In EMR> = "Y" OR CE<CCM Consent In EMR> = "y"{Time that contact started: <BR>«REQ»«.Time» <BR>Time that contact ended: <BR>«REQ»«.Time» <BR>Time spent for contact (subtract date note opened up from Time end above): <BR>.CE: CCM Time: «REQ» <BR>Monthly Total CCM: <BR>Monthly to date (minutes): ||CE<CCM Time Cumulative>[-date]|| in minutes (may be zero) <BR>New Cumulative (just minutes the number - see below): <BR>.CE: CCM Time Cumulative : «REQ» <BR>}ELSE {.}||Initials: «REQ»

CCM and paper

Demo of Clinical Elements Progression

Care Plan added as Care Time Thresholds reach/near 20 minutes (if not already done)

How do you build your CCM Registry?

You can build your registry from the ‘get go’ by taking the CCM list of patients from your PPRNET report. Then add them to your registry by using a batch process. This is just to create a list (you still have to get their consent)

Or… you can add qualifying patients as you see them.

We have quicktext at the start of every template (originally for meaningful use). Clicking on it will activate a lot of quicktext but at the end we’ve added the following to help ‘build’ our registry and get the consent done.

Sometimes the spouse is also at the visit – we just add a quick note to their chart which adds them and gets the consent done for them also. (see prior quicktext – Consent Given page)

Care Plan Template – a work in progressWe are still refining our CARE PLAN template and processes. This care plan is made available via the webportal (Webview) to allow the patients and families access to the care plan which is part of the regulation. See the setup document to the right (below).

To the left is the link to the care plan we have developed so far…

This care plan is in RTF format (compliments JFPM PDF version). This format allows for flexibility getting into your templates. (PP users – file sharing and forum section of EMR Village will have other versions/updates in the future)

Our staff (usually the “CCM Nurse”) willgenerate the care plan. We are pushing ourpatients to access the portal and look at thecare plan. To the right is how we set it up inWebview.

WEBVIEW SETUPCARE PLAN

Templates and Quicktext - continuedMore can be added as needed --- incorporating Clinical Elements and other codes to help with process flow.

This is a tool from the Institute for Health Improvement which may be helpful regarding getting a concept of shared planning.

QUICKTEXTS

CARE PLAN TOOL

To the right is the link to the quicktexts we use.This is a plain text file (CCMQuickText.txt). So… if creating quicktext, you may have to recreate the labels.

Knowledge BaseAlthough beyond the scope of this webinar, you can create links to the various documents andresources previously mentioned.

This helps your staff have them at hand or when you are training a new employee. See the resources below.

Racing with the machine

Productivity Paradox for IT / Technical vs Adaptation Problems (a.k.a. Challenges)

Erik Brynjolfsson. PhD - MITProductivity Paradox for IT 1. Don’t have ways of measuring productivity2. Unlocking IT’s potential requires the turning of two keys—the technology

itself and the redesign of the surrounding environment

Ronald Heifetz, MDTwo types of problems: technical and adaptive1. Technical problems require a recipe – follow the recipe to the solution2. Adaptive problems – require people to change and redesign their

environment

Understanding the Hype Cycle

1. Technology Trigger2. Peak of Inflated Expectations3. Trough of Disillusionment4. Slope of Enlightenment5. Plateau of Productivity

Gartner Consulting Group, 1995, Hype Cycle, http://www.gartner.com/technology/research/methodologies/hype-cycle.jsp#

CCM Challenges - Staff

CCM ?..!..?

Process development is a good thing.

But the rubber first meets the road with your staff.

Your staff, with discussion and their feedback, can be a GREAT “VETTING BED” for good ideas (including CCM).

CCM Challenges - Staff

Concepts:

• “Value” and “Analogies”• Survival and Frogs• PDSA Cycle

CCM Challenges - Staff• What’s the ‘buy in’?

• The VALUE PROPOSITION• “What difference will it make for me”?• “What difference will it make for the patients?”

• What’s the history?• at SFP – standing orders

• STAFF VALUATION PARADOX• paralegals – NO, dental hygienists – YES!

Are your staff practicing at the highest level of their competency and/or licensure?

Staff satisfaction is DIRECTLY related to difference they feel they make and the value they bring!

CCM Challenges - Staff

The water’s great isn’t it! • Start early and review

• Small steps –• Slowly increase

• Complexity• Responsibilities

• Survival concept• “The new reality”

On FROGS and SURVIVAL

CCM Challenges - Staff• Concept of PDSA cycle

• PLAN• DO• STUDY• ACT

Vetting ideas with the staff is invaluable

Acting on the changes

Cycling back to see if ideas, plans and actions worked.

What didn’t workSometimes what you develop doesn’t work for various reasons:Inefficiency leads the list – examples:• A process adds too many clicks or steps for staff to follow – that is, it really is

not efficient. • Duplication of effort – this is a fine balance sometimes (a good example is having

staff enter demographics into the EHR and the billing program)• Wrong staff member doing the process – you generally want the person doing a

task when they are at the highest level of their training/licensure. An example, may be to have a scanning technician/receptionist reassigned to call patients about dilated eye exams (i.e.: Call to see if the exam done. Can we make an appointment?, etc.) But, you might not want them calling patients about medications for medication reconciliation (that would be best done by a nurse or MA).

Most efficient steps/processes are easily incorporated into workflows by most people. This is especially true if, at a staff meeting, the process is explained and the value.

What follows is an example that didn’t work….

Message QT – didn’t work!

Quicktext that is ‘dropped’ (activated) within a message, will takethe .CE: code and make it Clinical Elements:

Message QT – didn’t work!

Concept was to get the message template to work – but as many know, dot codes (as shown above) are not ‘stateful’ and when the note is saved, the dot code doesn’t work and data doesn’t flow to the clinical elements.

Turns out the message template (not QuickText does work) and the Clinical Elements dot codes do remain stateful. A PDSA opportunity?

Message Template does work?

Recruitment/Retention

A few patients are just not going to sign on the first presentation of Chronic Care Management.

Lots of reasons:1) Trouble processing – for various reasons, folks may feel

“pushed” (not matter how open ended and soft the presentation) or they may have a yet unknown mild cognitive impairment or have been told “Never sign a form” until shown to another.

2) Mistrusting – we can thank our media for much of this but sometimes it’s the family culture they grew up in or that’s their personality.

3) Cost – some are so worried about costs that when presented, they push back.

4) Probably other reasons…

Recruitment/Retention

A solution that works to some extent:

The front sends me a message about the patient’s refusal.

We’ve created a letter template so I inform the staff to send it the next day. We’ve had over half of that small number of folks reconsider.

Recruitment/RetentionNo matter how well you may have laid out the benefits for CCM, some patients may subsequently “OPT OUT” which is their right. We tell patients that they can revoke CCM at any time. However, they must do so in writing.We need that documentation in writing.

We scan that document (the revocation letter) into a section of the patient’s chart known as ‘Documents’.

Attached in that note is another data element known as “CCM In Out”. That clinical element then ports to the registry to alert staff that the patient has opted out.

Recruitment/RetentionTracking CCM patients who have signed on have a suffix of “CCM” at the end of their chart number to easily identify them. Like in the previous example, one more letter will be sent if they REVOKE the CCM benefit (similar to the “CCM Plea letter” to giving them a chance to reconsider). Some have. But if they are resolute in their decision, the prior “CM” at the end of the chart number goes to “CO” to easily identify them in the future. We don’t want to keep asking them to sign on!

CHART number changes, for example, from “99999CM” to “99999CO”.

Likewise, the CCM registry (after scanning) has the “CCM In Out” as “OUT” so that even if staff work the registry, they know NOT to do CCM work on that particular patient who has opted out. Of course, if the patient changes their mind, we can change it back.

The scanning tech scans the letter in with quicktext “.CE: CCM In Out: OUT”This way, we have their revocation on record.

FIRST STEPS with patients

Use of Webviewcritical for our use of messagingand Instant Medical History…

Instant Medical History

Message Templates

Instant Medical History Message Templates

Now what? Starting actual management

You are now ready to “GO LIVE”!

We decided to have the managers (or leaders) involved in development of the CCM process to actually do test runs on individual patients.

This is where the PDSA (Plan-Do-Study-Act) cycles were helpful in making the changes necessary before moving the process to ‘general availability’ and use.

Gaining momentum… CCM has started!As you roll out your plan… keep your staff assessed of what you want done and listen to what they tell you (again, using the PDSA cycle). Having regular meetings with staff will help you understand how to further refine the CCM process.

The CCM is patient-centered but is also very task oriented. Listen to the patients….

Sometimes the patients will give you hints for changes that need to be made. Our video is probably our 4th major iteration based on feedback from initial patients who saw it. One patient commenting on an earlier version said, “Nice video, BUT…I really wanted to know more about the consent…”

How do “I” do CCM?

Eligible CCM patients

High Intensity/encounterLow # of contacts per

patient with less patients taken care of

CCM Nurse RESULT

Less patient encountersLess 20 m thresholds met

Having a staff member sit down and work the registry to help patients is surely a GOOD THING. Consider this, just reaching the 20 min threshold on 100 patients is 2000 minutes 33+ HOURS!

We had thought of 4 hours per week so we would only reach half that many patients! (16 hours per month vs. 33+ hours)

The power of team managementEligible CCM patients

The is no “I” in TEAM

Low Intensity/encounterHigh # of contacts per

patient with more patients taken care of

Entire staff(Clinician, Nursing, Front)

RESULT

More patient encounters….

More 20 minute thresholds met

Using the power of the EHR and involving the entire staff, you can help more patients and you will reach the 20 min billable threshold on more patients. Example: 5 staff spending ~5 min on 10 patients per day x 20 days/m = 5000 min 250 patients reaching a 20 min threshold. This is just in doing the usual tasks to take care of patients on a daily basis. That’s without the dedicated CCM nurse! The nurse could then take the more involved cases!

CCM calendar sensitive events

CCM Nurse Time

CCM 1st Assessment

CCM Management

CCM 2nd Assessment

CCM “Mop up” and Billing

CCM Last Assessment

Working the registry – the huddle

The huddle is your time to work as a team on the CCM registry or to decide what tasks you can accomplish for any group of patients.

Remember, any action for the patient will lead to better care for that patient.

Sit down with the CCM staff member who will work the registry and decide what tasks need to be accomplished for any given period you’ve designated.

Although this document will, no doubt, be subsequently changed, here is the link toour CCM Task List. We use this document to start each huddle. We keep these in a notebook for future reference.

CCM_Task_List document

Working the registry – huddle ideas

During the huddle, you may want to consider tasking based on the following items that need to be addressed for that patient (or group of patients):

Initial steps:• Get the contacts updated• Is an Advance Medical Directive available and in the chart?• Form to get Care Plan goals listed an then inputting into chart.• What are the goals of care of the patient (and care team) – based on the form

• Getting the care plan updated and into the chart

• Getting family or the patient on board with the web portal (Webview)• Risk (and/or SQUID) designation (to help with later tasking by risk strata)

• You would be using the PPRNET PLR report in conjunction with the registry

Working the registry – other huddle ideas

Later as you and your staff have dealt with improving “chart hygiene” (that is, getting all the data needed into the chart) and getting the care plan taken care of:

• Medication reconciliation and pre-emptive refills.

• Coordinating with home health, ACO case managers, etc.

• Health maintenance items or quality measures addressed • Such as scheduling appointments for mammogram, dilated eye exam appointment,

etc.

The idea is to have staff work with the registry of patients by tasks (although some patients may need more urgent individual attention). But, it is probably a good idea to have a “checklist” of things to check and/or arrange for each patient for each encounter.

SFP Performance thus Far

We’ve talked about the re-engineering with SFP

Let’s talk about…

1. Financial2. Outcomes

2

31 33

49

61

41

71

Jan Feb March April May June July

PATI

ENTS

2015

CCM Patients Reaching 20 min Threshold

CCM submission to Medicare

Jan Feb March April May June July

$110

$1,705 $1,815

$2,695

$3,355

$2,255

$3,905

Totals 288 Pts $15,840 Jan 1 through July 2015

SFP Patient Population - OutcomesEarly Benefits

1. We are working down the Health Maintenance (measures)2. More aware of patients medication world3. Some reduced calls (although we’re making more), more use of Webview4. Forms don’t hurt so much!5. Staff more engaged

Later Benefits – yet to see1. Some sense of reduced hospitalization and ER visits (hard to measure outside

of the practice)2. Better coordination of care with case workers, home health3. Reaching the TRIPLE AIM? (improving the patient experience [quality and

satisfaction], improving population health and reducing per capita cost.)

CCM Processes on the SFP horizon

CCM Processes on the SFP horizon

• Further Refinements in Webview• Clinical Elements for Webview• Adding logic to check for Webview• Welcome to Webview message

• Working more with PPRNET reports• Grouping of specific CCM patients by QM’s• Using the SQUID number to track patients• Using Risk Stratified Care Management

CCM Processes on the SFP horizon

• Working more with the Care Plan process• Refining Instant Medical History processes• Engaging patients and families

CCM Processes on the SFP horizon

What is on your CCM Horizon?

LOVELACE FAMILY MEDICINE

700+ CCM patients registered (June 2015)

Similar processes (not as automated) used by Dr. Lovelace and his staff. Consents and care plans get into the EMR for recording purposes.

Their time logging process to reach the 20 minute threshold is a little different.

A “CCM” provider is created. When processes qualifying for CCM are done on a patient, the CCM provider is carbon copied (CC:) in a message using the messaging with the amount of time noted.

At the end of the month, a staff member logs in as the CCM provider and goes to the “in-box” of the CCM provider. They then go through each message and add up time for each CCM patient. Those reaching threshold are submitted to Medicare.

The simplicity of the process is also the elegance of this process. Anyone using an EMR can use their messaging to log the CCM time ‘on the fly’ and then recapture it at the end of the month.

Practice Partner / EHR User Resources for CCM

The Practice Partner ListservOn Google (join EMR Village for instructions)

McKesson SocialText (only mildly helpful – IMHO)

And…

EMR Village File Sharing (Document Management System)

EMR Village Forum

Will be doing a deep dive on CCM on August 27, 2015 1-4 PMat the PPRNET meeting in Charleston, SC

with ….Jan Bradd, RN, BSN

You can reach me at

fbradd@shentel.net

Thanks for your interest and I look forward to your great ideas!

Thanks Oscar for your great inspiration!