[PDF] - None of the speakers: CCM Overview The CCM Team Michelle Thomas PDF Document

SLIDE 1

9/1/2017 1

Chronic Care Management

Collaborating with Pharmacists to Improve Care for Medicare Beneficiaries

Illustrate what Chronic Care Management(CCM) services

are and how pharmacists and thenicians can engage in implementation and maintenance of the service

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

needed while implementing CCM

Describe National resources tht are available for

pharmacists and technicians to use when developing and implementing programs

Learning Objectives Financial Disclosure None of the speakers:

Michelle Thomas
Kayla Craddock
CindyWarriner

have anything to disclose

CCM Overview
The CCM Team
CCM and CPAs in a Primary Care Practice
Resources and Billing
Video highlighting an ongoing trial
Business Case for CCM Partnerships
Adding Value through CCM
Panel Discussion
Questions & Discussion

Overview CE Evaluation Questions

1. When defining the Chronic Care Management (CCM)

team, nationally certified technicians may be classified as

clinicians. T or F
2. Which statements best describe Chronic Care

Management (select all that apply):

a. CCM is an example of a team based approach to

quality patient care

b. CCM may only be performed in a physician office
c. CCM patient consent may be verbal or written but

must be documented in the patient chart

d. a and c
3. Collaborative practice agreements are required for CCM
implementation. T or F
4. Identify the required elements for CCM (select all):
a. Documentation is captured in the HER
b. Patient consent
c. Patient must have two or more diagnosed chronic

care conditions

d. A mutually agreed upon care plan that will be

implemented by the clinician

e. All of the above

CE Evaluation Questions… cont.

SLIDE 2

9/1/2017 2

CCM Overview

Cindy Warriner, BS, RPh, CDE

Opportunity to improve patient outcomes and

quality metrics

Improved coordination of and access to care

for patients

Enhanced collaboration between physicians

and pharmacists

Optimizing clinicians’ time using a team-

based care model

Additional revenue for participating clinicians

CCM Value Proposition

Medicare Part B fee-for-service program

that pays providers for furnishing non- face-to-face chronic care management and coordination services each month.

Often provided telephonically

What is CCM? CCM Key Components

Structured Data Recording Comprehensive Care Plan 24/7 Access to Care Comprehensive Care Management Transitional Care Management

Medicare beneficiaries who reside in the community setting that meet the following requirements:

2+ significant chronic conditions expected to last

12+ months or until death

Significant risk of death, acute

exacerbation/decompensation, or functional decline (e.g. diabetes, heart failure)

Comprehensive care plan is established,

implemented, revised, or monitored

Eligible Patients Types of CCM

CCM Service Time Description Comprehensive Assessment N/A Extensive assessment & care planning during CCM enrollment (add-on to primary service) CCM 20+ minutes 5 core CCM services Complex CCM 60+ minutes 5 core CCM services plus: ∙ Moderate or high complexity clinical decision making ∙ Establishment or substantial revision of care plan Additional CCM Time 30 minutes increments Same as Complex CCM, added onto when time required exceeds the 60 minute baseline rate (e.g. 90 or 120 minutes)

SLIDE 3

9/1/2017 3

The CCM Team

CCM care team member can be classified

into three categories based on their profession and role on the team:

Qualified Healthcare Professionals (QHP)
Clinical Staff (e.g. pharmacists)
Non-clinical Staff

The Care Team

QHPs and clinical staff do not need to be co-

located when CCM services are provided

General Supervision: QHP needs to be generally

available (e.g. via phone) to the clinical staff when services are delivered

There are no restrictions on where non-clinical

staff can be located

Location of the Care Team

Care Team Roles and Responsibilities

Qualified Healthcare Professional (e.g. Physician) Clinical Staff (e.g. Pharmacist) Non-clinical Staff (e.g. Pharmacy Staff, Office Manager)

Consent Patient

X

Collect Structured Data

X X X

Develop Comprehensive Care Plan

X

Maintain/Inform Updates for Care Plan

X X

Manage Care

X X

Provide 24/7 Access to Care

X X

Document CCM Services

X X

Bill for CCM Services

X

Provide Support Services to Facilitate CCM

X X

Michelle Thomas, PharmD, BCACP, CDE

CCM in a Primary Care Practice

Quinton, VA
Physician-owned, small practice
Care Providers: MDs, NPs, PAs
Team: MAs, Med Secs
Adding a Pharmacist:2011
Hiring arrangement
Role/Services

Chickahominy Family Practice

SLIDE 4

9/1/2017 4 What does this list describe?

Added follow up between provider visits
More time spent with patient
Improve adherence (meds and monitoring)
Educate patients (save provider time)
Patient Selection
Consent
Care Plan Development
Care Plan Implementation
Documentation/Communication

CCM Care Process

Eligible Patients Medicare beneficiaries, residing in community:

>2 chronic conditions expected to last >12 mo
Significant risk of death, acute

exacerbation/decompensation, or functional decline

69yo male taking:

Xarelto
Lasix
Lipitor
Lantus
Lisinopril
Metoprolol tartrate
Novolog

Good potential CCM patient?

57yo female obese smoker

Nasacort
Loratadine
Ferrous sulfate
Hydrochlorothiazide
Meloxicam

Good potential CCM patient?

“Qualified Healthcare Professional” initially offers service to patient

Physician*
Nurse Practitioner
Physician Assistant
Clinical Nurse Specialist
Certified Nurse Midwife

Patient Selection

SLIDE 5

9/1/2017 5

By provider:

A. Non-face-to-face
IF seen within 12 mo
B. In person office visit
Provider time spent enrolling= G0506

Consent:How

A. Verbal
Document info was covered
B. Written
Scan form

Consent: Documentation

Required information for patient and/or caregiver:

What the CCM service is
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

Problem list
Expected outcomes
Measurable treatment

goals

Symptom management
Planned interventions
Medication management
Community/social

services ordered

Service coordination plan
Annual care plan review

Comprehensive Care Plan Suggested Elements:

Share With Required? How Patient/Caregiver yes

Written or electronic

Provider yes

In medical record
Electronically
Faxed
Secure messaging

Other health providers as appropriate

Sharing the Care Plan

By Clinical Staff:

Under supervision of QHP
General supervision: QHP’s presence is not required during the

performance of the service

Allowed to provide professional services
Cannot individually bill for services

Care Plan Implementation Monthly telephone calls by Clinical Staff:

Comprehensive Care Management
Prevention
MTM
Help with care transitions
Help with referrals
Outline 24/7 Access to Care

Care Plan Implementation

SLIDE 6

9/1/2017 6

Use standardized process (VDH resources) Collaborative Practice Agreement Quality standards immunizations ASA as appropriate

Care Plan Implementation

Demographics
Problem list
Medications, allergies
Consent
Care plan
Documentation that care plan was provided to

patient

Communications to and from providers
Time spent delivering CCM services

Documentation:Clinical Staff

Documentation requirements for *QHPs

(provider)

Must be captured in EHR:

* Clinical staff not required to have certified EHR, but should document these items

Consent Performed, Date Care Plan Care Management Communications Document Care Plan was Provided Time Spent on Patient Discussion

Advancing Team-Based Care Through the Use of Collaborative Practice Agreements and Using the Pharmacists’ Patient Care Process to Manage High Blood Pressure

Kayla Craddock, MPH

Virginia Department of Health

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

Hypertension Burden in Virginia

SLIDE 7

9/1/2017 7

Hypertension Hospitalization in Virginia

Diabetes Burden in Virginia

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

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 monitoring, lifestyle modification, and medication therapy management.

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

Pharmacists’ Patient Care Process (PPCP)

“Using the PPCP to Manage High Blood Pressure: A Resource Guide for Pharmacists”

https://www.cdc.gov/dhdsp/pubs/docs/pharmacist- resource-guide.pdf

SLIDE 8

9/1/2017 8 Collaborative Practice Agreements

“Advancing Team-Based Care Through Collaborative Practice Agreements: A Resource and Implementation Guide for Adding Pharmacists to the Care Team” https://www.cdc.gov/dhdsp/pubs/docs/CPA-Team- Based-Care.pdf

Collaborative Practice Agreements (cont.)

“Methods and Resources for Engaging Pharmacy Partners”

https://www.cdc.gov/dhdsp/pubs/docs/engaging- pharmacy-partners-guide.pdf

Code of Virginia

"Collaborative agreement" means a voluntary, written, or electronic arrangement between one pharmacist and his designated alternate pharmacists involved directly in patient care at a single physical location where patients receive services and…….

http://law.lis.virginia.gov/vacode/title54.1/chapter33/

Resources

Plan for Well-Being

http://virginiawellbeing.com/

Data portal

http://www.vdh.virginia.gov/data/

LiveWell

http://www.vdh.virginia.gov/vdhlivewell/

Kayla Craddock, MPH | Quality Improvement Supervisor kayla.craddock@vdh.virginia.gov

Emporia Video

Panel Discussion

Kayla Craddock, MPH Michelle Thomas, PharmD, CDE Facilitated by: Cindy Warriner

SLIDE 9

9/1/2017 9

The Business Case for Physician/Pharmacist CCM Partnerships

Michelle Thomas, Pharm D, CDE

Logistics
Value
Patient care
Provider time savings
Quality Measure improvement
Revenue
Questions to consider

Selling the Pharmacist/Provider Partnership: Contractual Relationships to Meet Incident to Requirements

Directly Employed

Clinical staff hired as employee of QHP or practice (W-2 tax form)

Leased Employment

Relationship between two employers such that one employer hires

the services of the other

Independent Contractor

Clinical staff individually contracts for work (IRS-1099 tax form)

CCM team members must be contracted, leased, or employed by QHP

QHP partners with pharmacists
Pharmacists provide CCM service elements
Pharmacist/pharmacy paid a portion of revenue

(reflects % of services provided).

❑ PCP contracting with community pharmacist ❑ Clinic employing pharmacist ❑ Group practice leasing a pharmacist from his/her primary practice setting

Partnering with Pharmacists

Improved coordination of care
Improved access
More attention to patient needs
Improved health and satisfaction

Value Proposition: Patient Care

Patient phone calls for refills
Care coordination - specialist notes,

communication

Home Health collaboration - supplies, feedback
Referral follow-through
Screen/triage less serious patient issues

Value Proposition: Provider Time

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9/1/2017 10

Potential to improve key quality metrics and patient
utcomes
Sample measures of interest:
Patients with A1C > 9.0%
Medication reconciliation post discharge
Influenza/Pneumococcal immunization
Tobacco screening and counseling
Blood pressure screening and control

Value Proposition: Quality Measures

CCM billing $40-$100+/month per patient ($500+

annually)

Improved quality metrics can lead to incentive

payments (e.g. MACRA/MIPS)

Increased timely follow up when appointments

due

Improved practice reputation, new patient draw

Value Proposition: Improve Revenue CCM Billing Basics

Comprehensive Assessment CCM Complex CCM Additional CCM Time Duration of Services Once per QHP, patient 20+ minutes >60 minutes 30 minute increments AFTER 60 mins CPT Code G0506 99490 99487 99489 Services Extensive assessment & care planning during CCM enrollment (QHP add-on code) 5 core CCM services 5 core CCM services plus: ∙ Moderate or high complexity clinical decision making by the QHP ∙ Establishment or substantial revision

f care plan

Same as Complex CCM

Avg. 2017

payment $64 $43 $94 $47

Potential Partnership Scenario

Income scenario (also add-on fee for QHP):

Minimum $42.60/patient/month x 100 patients
$4,260 per month X 12 months = $51,120 per year

Revenue share example: Pharmacist provides 80% of CCM service=80% of billed visits/month.

Copayments & deductibles DO apply
Patient may pay 20%
Often covered by Medigap
No copay for duals

CCM Billing Basics

ONLY QHPs bill for CCM

(provider status issue)

One practitioner paid per patient
Only billed once per month

CCM Billing Basics

SLIDE 11

9/1/2017 11

May not bill in the same month (duplication):
Transitional Care Management (99495, 99496)
Home Health Supervision (G0181)
Hospice Care Supervision (G9182)
Certain ERSD Services (90951-90970)
Patient Monitoring Services (99090, 99091)

CCM Billing Basics

Who to enroll
Patient outreach plan
EHR capabilities/access
Mechanism for communicating
Does QHP already bill duplicative services (TCM,

HH etc.) & how to avoid issues

Care team members, division of responsibilities
Processes: identifying, consenting, withdrawing

patients

Considerations for CCM Collaboration

CMS Guidance on Chronic Care Management Services
2017: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNProducts/Downloads/ChronicCareManagement.pdf

CMS FAQs on CCM
2017: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/PhysicianFeeSched/Downloads/Payment_for_CCM_Services_FAQ.pdf

CMS Summary of CCM Changes for 2017
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNProducts/Downloads/ChronicCareManagementServicesChanges2017.pdf

Medicare Learning Network National Provider Call on CCM
https://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2015-02-18-CCM-

Transcript.pdf

CCM: An Overview for Pharmacists
https://www.pharmacist.com/sites/default/files/CCM-An-Overview-for-

Pharmacists-FINAL.pdf

CCM Resources CE Evaluation Questions

1. When defining the Chronic Care Management (CCM)

team, nationally certified technicians may be classified as

clinicians. T or F
2. Which statements best describe Chronic Care

Management (select all that apply):

a. CCM is an example of a team based approach to

quality patient care

b. CCM may only be performed in a physician office
c. CCM patient consent may be verbal or written but

must be documented in the patient chart

d. a and c
3. Collaborative practice agreements are required for CCM
implementation. T or F
4. Identify the required elements for CCM (select all):
a. Documentation is captured in the HER
b. Patient consent
c. Patient must have two or more diagnosed chronic