9/1/2017 Learning Objectives • Illustrate what Chronic Care Management(CCM) services are and how pharmacists and thenicians can engage in implementation and maintenance of the service Chronic Care Management • Identify strategies that care teams may utilize for reimbursement/sustainability of their services in the CCM model of care • Recognize when a collaboratative practice agreement is Collaborating with Pharmacists to Improve needed while implementing CCM Care for Medicare Beneficiaries • Describe National resources tht are available for pharmacists and technicians to use when developing and implementing programs Financial Disclosure Overview • None of the speakers: CCM Overview • The CCM Team • Michelle Thomas • CCM and CPAs in a Primary Care Practice • • Kayla Craddock Resources and Billing • Video highlighting an ongoing trial • CindyWarriner • Business Case for CCM Partnerships • Adding Value through CCM have anything to disclose • 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) implementation. T or F team, nationally certified technicians may be classified as 4. Identify the required elements for CCM (select all): clinicians. T or F a. Documentation is captured in the HER 2. Which statements best describe Chronic Care b. Patient consent Management (select all that apply): c. Patient must have two or more diagnosed chronic a. CCM is an example of a team based approach to care conditions quality 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 e. All of the above must be documented in the patient chart d. a and c 1
9/1/2017 CCM Value Proposition • Opportunity to improve patient outcomes and quality metrics • Improved coordination of and access to care for patients CCM Overview • 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 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 and coordination services each month. Recording Care Plan to 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 Complex CCM 60+ minutes 5 core CCM services plus: 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 2
9/1/2017 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 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 staff can be located Manage Care 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 3
9/1/2017 What does this list describe? CCM Care Process • Added follow up between provider visits • Patient Selection • More time spent with patient • Consent • Improve adherence (meds and monitoring) • Educate patients (save provider time) • Care Plan Development • Care Plan Implementation • Documentation/Communication Good potential CCM patient? Eligible Patients 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 • Ferrous sulfate o Nurse Practitioner • Hydrochlorothiazide o Physician Assistant • Meloxicam o Clinical Nurse Specialist o Certified Nurse Midwife 4
9/1/2017 Consent:How Consent: Documentation By provider: A. Verbal • 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 Care Plan Development Sharing the Care Plan Comprehensive Care Plan Suggested Elements: • • Problem list Medication management Share With Required? How • • Patient/Caregiver yes • Written or electronic Expected outcomes Community/social services ordered • Provider yes • In medical record 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 • Help with care transitions • Cannot individually bill for services • Help with referrals • Outline 24/7 Access to Care 5
9/1/2017 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 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 Management Document Care Kayla Craddock, MPH Communications Plan was Provided * Clinical staff not required to have Time Spent on certified EHR, but Patient 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 6
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