OBJECTIVES FACTS AND FIGURES CMS CHRONIC CARE MANAGEMENT 10/20/2015. Another Step Towards Care Coordination

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1 CMS CHRONIC CARE MANAGEMENT Another Step Towards Care Coordination Care Coordination Patient/ Family Community Resources APARNA GUPTA, CRNP, MSN, PGDBA Transitions of Care Chronic Diseases OBJECTIVES AT THE END OF THIS SESSION, THE AUDIENCE WILL BE ABLE TO : UNDERSTAND CHRONIC CARE MANAGEMENT (CCM) AND THE NEW CENTER FOR MEDICARE AND MEDICAID SERVICES (CMS) CCM BILLING CODE UNDER THE REVISED PHYSICIAN FEE SCHEDULE, 2015 IDENTIFY THE VARIOUS CRITERIA REQUIRED FOR CHRONIC CARE MANAGEMENT BILLING CODE IDENTIFY AND EXPLAIN THE IMPACT OF CHRONIC CARE COORDINATION AND REIMBURSEMENT IN THE CONTEXT OF CHRONIC CARE MANAGEMENT AND PATIENT COST SHARING. FACTS AND FIGURES BETWEEN 2000 AND 2010, THE POPULATION 65 YEARS AND OVER INCREASED AT A FASTER RATE (15.1 PERCENT) THAN THE TOTAL U.S POPULATION (9.7 PERCENT). US CENSUS BUREAU DATA ESTIMATION FOR US POPULATION OF ADULTS AGE 65 AND OLDER MILLION MILLION MILLION LIFE EXPECTANCY MALE AGE 65 TODAY -> EXPECTED TO LIVE UNTIL AGE FEMALE AGE 65 TODAY -> EXPECTED TO LIVE UNTIL AGE MEDICARE SPENDING IS PROJECTED TO INCREASE FROM $555 BILLION IN 2011 TO $903 BILLION IN CENTERS FOR DISEASE CONTROL AND PREVENTION. THE STATE OF AGING AND HEALTH IN AMERICA ATLANTA, GA: CENTERS FOR DISEASE CONTROL AND PREVENTION, US DEPT OF HEALTH AND HUMAN SERVICES;

2 POPULATION GROWTH AND THE ELDERLY THE BACKGROUND ON CHRONIC CARE Multiple chronic conditions among Medicare fee-for-service beneficiaries, 2010 THE BACKGROUND ON CHRONIC CARE Chronic Conditions as leading causes of death,

3 LEADING CHRONIC CARE TODAY CENTERS FOR MEDICARE AND MEDICAID SERVICES INSTITUTE OF MEDICINE, 2001 CROSSING THE QUALITY CHASM: A NEW HEALTH SYSTEM FOR THE 21 ST CENTURY INSTITUTE FOR HEALTHCARE IMPROVEMENT ROBERT WOOD JOHNSON FOUNDATION THE AGENCY FOR HEALTHCARE RESEARCH AND QUALITY NATIONAL COMMITTEE FOR QUALITY ASSURANCE THE JOINT COMMISSION ARE WE ANY CLOSER TO THE TRIPLE AIM? CHRONIC CARE AROUND THE WORLD THE WORLD HEALTH REPORT 2002 REDUCING RISKS, PROMOTING HEALTHY LIFE - PROMOTE PREVENT TREAT CARE MORTALITY, MORBIDITY AND DISABILITY ATTRIBUTED TO - CARDIOVASCULAR DISEASES, CANCER, DIABETES, CHRONIC RESPIRATORY DISEASES, AND UNDERLYING DETERMINANTS OF HEALTH CURRENTLY ACCOUNT FOR : ALMOST 60% OF ALL DEATHS AND 43% OF THE GLOBAL BURDEN OF DISEASE BY > WILL INCREASE TO 73% OF ALL DEATHS AND 60% OF THE GLOBAL BURDEN OF DISEASE. 3

4 WHAT IS CHRONIC CARE MANAGEMENT What is the contextual definition? THE GOOD OLD DAYS HOUSE CALLS FOCUS ON LONGSTANDING RELATIONSHIP WITH PATIENT AND FAMILY RELIANCE ON SOCIAL SUPPORT AND COMMUNITY (CHURCH, SYNAGOGUE, NEIGHBORS, EXTENDED FAMILY) LIFE EXPECTANCY? MORBIDITY AND MORTALITY? CHALLENGES IN GERIATRIC CARE Lack of Care Coordination Polypharmacy Patients Inadequately Trained Medication Reconciliation Physical and Mental Impairments Lack of Active Follow Up Gaps in Transitions Geriatric syndromes 4

5 EXISTING MODELS OF CARE DELIVERY IMPROVING CHRONIC ILLNESS THE CHRONIC CARE MODEL GRACE GERIATRIC RESOURCES FOR ASSESSMENT AND CARE OF OTHERS PATIENT CENTERED MEDICAL HOME PROGRAM FOR ALL INCLUSIVE CARE OF THE ELDERLY TRANSITIONAL CARE MODELS SO WHAT S THE BIG DEAL WITH CCM? PARADIGM SHIFT MOVING TOWARDS VALUE BASED CARE PATIENT - CENTERED, GOAL DRIVEN CARE THE HEALTH-DISEASE SPECTRUM -> DISEASE FOCUS OR HEALTH PROMOTION? SHARED DECISION MAKING TRANSPARENCY IN CARE, CLOSE THE GAPS ACROSS TRANSITIONS RECOGNITION OF CARE COORDINATION EFFORTS FOR REIMBURSEMENT IS THIS THE PATH TO NEW PAYMENT MODELS FOR CHRONIC HEALTH (NOT DISEASE) - CARE MANAGEMENT??? CMS CHRONIC CARE MANAGEMENT IN CALENDAR YEAR (CY) 2015, CMS WILL BEGIN MAKING SEPARATE PAYMENT UNDER THE MEDICARE PHYSICIAN FEE SCHEDULE (PFS) FOR CHRONIC CARE MANAGEMENT (CCM) SERVICES UNDER CURRENT PROCEDURE TERMINOLOGY (CPT) CODE CCM SERVICES ARE NON-FACE-TO-FACE CARE MANAGEMENT/COORDINATION SERVICES FOR CERTAIN MEDICARE BENEFICIARIES HAVING MULTIPLE (TWO OR MORE) CHRONIC CONDITIONS. ( MLN/MLNPRODUCTS/DOWNLOADS/CHRONICCAREMANAGEMENT.PDF) 5

6 CMS CHRONIC CARE MANAGEMENT IN CASE YOU MISSED IT, HERE IS THE RECAP: CMS REIMBURSEMENT IS AVAILABLE FOR CARE COORDINATION SERVICES PROVIDED TO PATIENTS WITH TWO OR MORE EXISTING CHRONIC CONDITIONS, EXPECTED TO LAST AT LEAST 12 MONTHS OR UNTIL DEATH OF THE PATIENT REQUIRES AT LEAST 20 MINUTES OF NON FACE TO FACE CARE COORDINATION BY CLINICAL STAFF, ON A MONTHLY BASIS REIMBURSEMENT ESTIMATED $ 42.60/ PER PATIENT/ PER CALENDAR MONTH REQUIRES PATIENT CONSENT AND THE REIMBURSEMENT IS SUBJECT TO PATIENT COST SHARING THIS IS WHERE THE STORY GETS INTERESTING. CMS CHRONIC CARE MANAGEMENT REQUIRES A COMPREHENSIVE CARE PLAN FOR ALL HEALTH ISSUES - TYPICALLY INCLUDES, BUT IS NOT LIMITED TO, THE FOLLOWING ELEMENTS: PROBLEM LIST EXPECTED OUTCOME AND PROGNOSIS MEASURABLE TREATMENT GOALS SYMPTOM MANAGEMENT PLANNED INTERVENTIONS AND IDENTIFICATION OF THE INDIVIDUALS RESPONSIBLE FOR EACH INTERVENTION MEDICATION MANAGEMENT COMMUNITY/SOCIAL SERVICES ORDERED A DESCRIPTION OF HOW SERVICES OF AGENCIES AND SPECIALISTS OUTSIDE THE PRACTICE WILL BE DIRECTED/COORDINATED SCHEDULE FOR PERIODIC REVIEW AND, WHEN APPLICABLE, REVISION OF THE CARE PLAN. CMS CHRONIC CARE MANAGEMENT THE OTHER REQUIREMENTS STRUCTURED DATA AND RECORDING ACCESS TO CARE MANAGE CARE EHR AND OTHER ELECTRONIC TECHNOLOGY REQUIREMENTS CANNOT BE BILLED DURING THE SAME SERVICE REQUIREMENTS AS CPT CODES , CODES G0181/G0182, OR CPT CODES , THERE MAY BE OTHER RESTRICTIONS (SPONSORED PROGRAMS, DEMONSTRATION PROJECT) 6

7 CCM The Case of R.S. THE CASE OF R.S. (CONTD.) 84 YR OLD AA FEMALE, LIVES INDEPENDENTLY IN A HIGH RISE APARTMENT BUILDING PERFORMS HER OWN ADLS. ASSIST WITH IADLS IS QUESTIONABLE (SHE SAYS SHE DOES HER OWN COOKING AND GROCERY WITH FOOD STAMPS). INDEPENDENT WITH AMBULATION. PMH INCLUDES REMOTE HISTORY OF BREAST MALIGNANCY, DM, HTN, CAD, UI, BILATERAL HEARING IMPAIRMENT, DEPRESSION AND DENTAL CARIES FAMILY HISTORY SIGNIFICANT FOR HTN IN BOTH PARENTS, AND BREAST CANCER IN MOTHER SOCIAL HISTORY NOTABLE FOR PAST EMPLOYMENT AS CASE WORKER IN SENIOR DAY CARE CENTER. NEVER MARRIED, MANY FAMILY MEMBERS INVOLVED IN DIFFERENT ASPECTS OF HER CARE, NON REALLY ENGAGED INITIAL ENCOUNTER, 18 MTHS AGO SHE IS PLANNING TO APPLY FOR EMPLOYMENT AT A SENIOR CARE CENTER IS STRUGGLING WITH FINANCES. I DON T NEED AGING HELP LIKE THOSE OTHER OLD PEOPLE OVERALL, HEALTH HAS BEEN PRECARIOUS CARE COORDINATION PRE EXISTING WITHIN THE FRAMEWORK OF MEDICAL HOME TARGETED PILOT WITH PATIENT PANELS OF THREE PHYSICIANS IN TWO OUTPATIENT GERIATRICS CLINICS HIGH RISK PATIENTS SELECTED WITH AT LEAST TWO OR MORE CHRONIC CONDITIONS SATISFYING CRITERIA COORDINATED BY CRNP -> WEEKLY INTERDISCIPLINARY TEAM MEETINGS COMPRISING CORE TEAM OF PCP, CRNP AND TEAM RN OTHER DISCIPLINES PRESENT AS NEEDED. 7

8 KEY ROLE OF PRACTICE BASED CASE MANAGER WHEN APPLICABLE. COMPREHENSIVE CARE PLANS CREATED AND REVISED DURING AND AFTER TEAM MEETINGS BY CRNP PATIENT COST SHARING CONSIDERING PRIOR TO DISCUSSING CONSENT ONLY THOSE PATIENTS WHO WERE CONSIDERED FINANCIALLY APPROPRIATE WERE APPROACHED FOR CONSENT PATIENT CONSENT FOR CCM SERVICES OBTAINED DURING PCP OFFICE VISIT, GOALS OF CARE ADDRESSED, SHARED CARE PLAN PROVIDED TO PATIENT. CONCURRENTLY, BILLING PROCESS AND DOCUMENTATION FLOWSHEET TEMPLATES PROVIDED BY IT DEPT. CONSENT FORM CREATED AND REVISED BY TEAM, REVIEWED AND APPROVED BY EXECUTIVE LEADERSHIP DOCUMENTATION DOTPHRASES CREATED AND DISSEMINATED TO TEAM BY CRNP INITIALLY CHART REVIEWS (TO ENSURE REIMBURSEMENT REQUIREMENTS ARE SATISFIED) AND BILLING SUBMITTED BY CRNP GRADUALLY TRANSITIONED TO RN COORDINATORS AND OFFICE STAFF PATIENT REGISTRIES MAINTAINED BY CRNP. PATIENT FOLLOW UPS AND CARE COORDINATION MANAGED BY TEAM COLLECTIVELY. BACK TO THE CASE OF R.S DIAGNOSED WITH CARCINOMA IN SITU OF BREAST HER-2+ -> WILL LIKELY REQUIRE LUMPECTOMY AND / OR MASTECTOMY POST SURGICAL CARE REMAINS QUESTIONABLE. FAMILY DISAGREES WITH POST SURGICAL DISPOSITION, IS UNWILLING TO DISCUSS ADVANCED CARE PLANNING FAMILY MEETING PLANNED WITH INTERDISCIPLINARY CARE TEAM, CLOSE FOLLOW UP AND CONSULTATION WITH SPECIALITIES INVOLVED CARE COORDINATION AT ITS BEST. IS R.S. A PART OF THE? 8

9 CHALLENGES CHANGE IN PRACTICE- INTEGRATE TIME SPENT DURING DOCUMENTATION MAINTAIN PATIENT REGISTRY NUANCES IN REIMBURSEMENT REQUIREMENTS COST TO PATIENT VS BARRIERS FACED BY PATIENT POPULATION OPPORTUNITIES TRUE CARE COORDINATION IN REAL TIME, ACROSS DISCIPLINES COMING TOGETHER OF IDEAS AND SHARE CONCERNS WITHIN THE TEAM SHARED DECISION MAKING AND TRANSPARENCY OF CARE PLANS GOALS OF CARE DISCUSSIONS CARE CAN BE PATIENT CENTERED! 9

10 ADDITIONAL RESOURCES : MLN/MLNMATTERSARTICLES/DOWNLOADS/SE1516.PDF MLN/MLNPRODUCTS/DOWNLOADS/CHRONICCAREMANAGEMENT.PDF MANAGEMENT/ THANK YOU 10