8/30/2017 Overview • CCM Overview • The CCM Team • CCM and CPAs in a Primary Care Practice Chronic Care Management • Resources and Billing • Video highlighting an ongoing trial • Business Case for CCM Partnerships Collaborating with Pharmacists to Improve • Care for Medicare Beneficiaries Adding Value through CCM • Panel Discussion • Questions & Discussion CE Evaluation Questions… cont. CE Evaluation Questions 3. Collaborative practice agreements are required for CCM 1. When defining the Chronic Care Management (CCM) team, implementation. T or F nationally certified technicians may be classified as clinicians. 4. Identify the required elements for CCM (select all): T or F a. Documentation is captured in the HER 2. Which statements best describe Chronic Care Management b. Patient consent (select all that apply): c. Patient must have two or more diagnosed chronic a. CCM is an example of a team based approach to quality care conditions patient care d. A mutually agreed upon care plan that will be b. CCM may only be performed in a physician office implemented by the clinician c. CCM patient consent may be verbal or written but must be e. All of the above documented in the patient chart d. a and c CCM Value Proposition • Opportunity to improve patient outcomes and quality metrics • Improved coordination of and access to care CCM Overview for patients • Enhanced collaboration between physicians Cindy Warriner, BS, RPh, CDE and pharmacists • Optimizing clinicians’ time using a team - based care model • Additional revenue for participating clinicians 1
8/30/2017 What is CCM? CCM Key Components • Medicare Part B fee-for-service program that pays providers for furnishing non- face-to-face chronic care management Structured Data Comprehensive 24/7 Access to and coordination services each month. Recording Care Plan Care • Often provided telephonically Comprehensive Care Transitional Care Management Management Eligible Patients Types of CCM Medicare beneficiaries who reside in the CCM Service Time Description community setting that meet the following Comprehensive N/A Extensive assessment & care planning during Assessment CCM enrollment (add-on to primary service) requirements: CCM 20+ minutes 5 core CCM services • 2+ significant chronic conditions expected to last 60+ minutes 5 core CCM services plus: Complex CCM 12+ months or until death • Moderate or high complexity clinical decision making • Significant risk of death, acute • Establishment or substantial revision of exacerbation/decompensation, or functional care plan decline (e.g. diabetes, heart failure) Additional CCM 30 minutes Same as Complex CCM, added onto when • Comprehensive care plan is established, Time increments time required exceeds the 60 minute baseline rate (e.g. 90 or 120 minutes) implemented, revised, or monitored The Care Team • CCM care team member can be classified into three categories based on their profession and role on the team: The CCM Team • Qualified Healthcare Professionals (QHP) • Clinical Staff (e.g. pharmacists) • Non-clinical Staff 2
8/30/2017 Location of the Care Team Care Team Roles and Responsibilities Qualified Healthcare Non-clinical Staff • QHPs and clinical staff do not need to be co- Clinical Staff Professional (e.g. Pharmacy Staff, (e.g. Pharmacist) (e.g. Physician) Office Manager) located when CCM services are provided Consent Patient X • General Supervision: QHP needs to be generally Collect Structured Data X X X available (e.g. via phone) to the clinical staff when Develop Comprehensive X services are delivered Care Plan Maintain/Inform Updates X X • There are no restrictions on where non-clinical for Care Plan Manage Care staff can be located X X Provide 24/7 Access to X X Care Document CCM X X Services Bill for CCM Services X Provide Support X X Services to Facilitate CCM Chickahominy Family Practice • Quinton, VA CCM in a Primary Care Practice • Physician-owned, small practice • Care Providers: MDs, NPs, PAs • Team: MAs, Med Secs • Adding a Pharmacist:2011 • Hiring arrangement Michelle Thomas, PharmD, BCACP, CDE • Role/Services What does this list describe? CCM Care Process • Added follow up between provider visits • More time spent with patient • Improve adherence (meds and monitoring) • Educate patients (save provider time) 3
8/30/2017 Eligible Patients Good potential CCM patient? 69yo male taking: Medicare beneficiaries, residing in community: • Xarelto • Lasix • >2 chronic conditions expected to last >12 mo • Lipitor • Lantus • Significant risk of death, acute • Lisinopril • Metoprolol tartrate exacerbation/decompensation, or functional • Novolog decline Good potential CCM patient? Patient Selection “ Qualified Healthcare Professional” 57yo female obese smoker initially offers service to patient • Nasacort o Physician* • Loratadine o Nurse Practitioner • Ferrous sulfate • Hydrochlorothiazide o Physician Assistant • Meloxicam o Clinical Nurse Specialist o Certified Nurse Midwife Consent:How Consent: Documentation A. Verbal By provider: • Document info was covered A. Non-face-to-face B. Written • Scan form • IF seen within 12 mo B. In person office visit Required information for patient and/or caregiver: • What the CCM service is • Provider time spent enrolling= G0506 • How to access the service • How patient’s information will be shared • How cost-sharing applies to these services • That only one QHP can be provide this service monthly • How to stop the service 4
8/30/2017 Sharing the Care Plan Care Plan Development Comprehensive Care Plan Suggested Elements: • • Problem list Medication management Share With Required? How • Written or electronic • • Patient/Caregiver yes Expected outcomes Community/social services ordered • In medical record • Provider yes Measurable treatment • Electronically • goals Service coordination plan Other health providers as appropriate • Faxed • • Symptom management Annual care plan review • Secure messaging • Planned interventions Care Plan Implementation Care Plan Implementation By Clinical Staff: Monthly telephone calls by Clinical Staff: • Under supervision of QHP • Comprehensive Care Management • General supervision : QHP’s presence is not required during the • Prevention performance of the service • MTM • Allowed to provide professional services • Cannot individually bill for services • Help with care transitions • Help with referrals • Outline 24/7 Access to Care Care Plan Implementation Documentation:Clinical Staff • Demographics Use standardized process (VDH resources) • Problem list Collaborative Practice Agreement • Medications, allergies Quality standards • Consent immunizations • Care plan ASA as appropriate • Documentation that care plan was provided to patient • Communications to and from providers • Time spent delivering CCM services 5
8/30/2017 Documentation requirements for *QHPs (provider) Must be captured in EHR: Advancing Team-Based Care Through the Use of Collaborative Practice Agreements and Using the Pharmacists’ Consent Care Plan Performed, Date Patient Care Process to Manage High Blood Pressure Care Document Care Kayla Craddock, MPH Management Plan was Communications Provided * Clinical staff not Time Spent on required to have Patient certified EHR, but Discussion should document these items Virginia Department of Health Hypertension Burden in Virginia Mission: Protect the health and promote the well-being of all people in Virginia. Vision: Become the healthiest state in the nation. 35 health districts Diabetes Burden in Virginia Hypertension Hospitalization in Virginia 6
8/30/2017 Diabetes Hospitalization in Virginia Guiding Principles and Practices • Team-Based Care • Pharmacists • Behavioral Therapists • Community Health Workers • Local Health Districts • Self-Measured Blood Pressure Monitoring • Self-Management Plans and/or Programs • Diabetes Prevention Programs • Diabetes Self-Management Programs Call for Applications Pharmacists’ Patient Care Process (PPCP) • The intent for this unique learning opportunity is to support the priorities…..by focusing on team -based approaches to hypertension control including self-measured blood pressure “Using the PPCP to monitoring, lifestyle modification, and medication therapy Manage High Blood management. Pressure: A Resource Guide for Pharmacists” • The purpose of this project is to accelerate the use of collaborative practice agreements and the pharmacists’ patient care process for the management of high blood pressure. • Selected States include: Arizona, Georgia, Iowa, Utah, Virginia , West Virginia and Wyoming https://www.cdc.gov/dhdsp/pubs/docs/pharmacist- resource-guide.pdf Collaborative Practice Agreements Collaborative Practice Agreements (cont.) “Advancing Team -Based Care Through Collaborative Practice “Methods and Resources for Engaging Pharmacy Partners” Agreements: A Resource and Implementation Guide for Adding Pharmacists to the Care Team” https://www.cdc.gov/dhdsp/pubs/docs/CPA-Team- https://www.cdc.gov/dhdsp/pubs/docs/engaging- Based-Care.pdf pharmacy-partners-guide.pdf 7
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