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.

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CCM OverviewCindy 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)

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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 PlanX

Maintain/Inform Updates

for Care PlanX X

Manage Care X X

Provide 24/7 Access to

CareX X

Document CCM

ServicesX 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

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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 patiento Physician*

o Nurse Practitioner

o Physician Assistant

o Clinical Nurse Specialist

o Certified Nurse Midwife

Patient Selection

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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

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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

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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

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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 DiscussionKayla Craddock, MPH

Michelle Thomas, PharmD, CDE

Facilitated by: Cindy Warriner

9/1/2017

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The Business Case for Physician/Pharmacist CCM

PartnershipsMichelle 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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• Potential to improve key quality metrics and patient

outcomes

• 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

of 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

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• 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

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.

Questions & Discussion