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Using Data to Improve Care for Complex Patients

Complex patients — those with two or more chronic conditions that are expected to last at least 12 months, or until death — make up only 5% of Medicare beneficiaries but astoundingly account for over half of the total costs. The care of these patients is often as complex as their health issues, and now is the time to start streamlining, with a view toward patient-centered care that eliminates extraneous and duplicative services.

Setting the stage

In January 2015, the Centers for Medicare and Medicaid Services (CMS) introduced payments for chronic care management under the code 99490. The reimbursement focuses around the care of the so-called super-users – those patients with complex and, often, multiple health issues. The ultimate goal is to improve the care of these patients.

However, many of these patients do not have a primary point of contact within the healthcare system. And, for these patients especially, it is critically important that they have one physician to oversee their entire care plan — the one person who knows what drugs have been prescribed and which tests have been ordered, and who also understands the social aspects in the patient’s life.

Having a designated, primary physician centralizes communication for the patient. For example, if a patient suddenly experiences a side-effect from a prescribed medication, then they can contact their go-to physician. If their medication isn’t working properly, then the physician can contact the patient via email or phone and change the dose.

Focusing on prevention

The key to managing complex patients is preventive care: The physician in charge of the patient’s care will have a much better understanding of the interplay of conditions (rather than viewing them in isolation), and will be able to offer advice, change prescriptions and generally manage the patient’s treatment regimen with the patient’s active participation — without the patient’s constantly having to come into the practice.

With the new reimbursement model created by CMS, the coordinating physician can bill for 20 minutes of non-face-to-face time per month. This can be achieved via phone calls or emails, and not just from the physician but also other staff in the practice including certified nurse midwives, clinical nurse specialists, nurse practitioners and physician assistants. This streamlines care from the patient perspective as, instead of having to call around amongst their treating physicians to get an appointment to discuss part of their care, the designated physician will assume the responsibility of coordinating care. The number of personal visits in the practice will be minimized and, ultimately, costs will be reduced.

But that brings us to the practicalities: setting up a workable, efficient system, knowing which patients to enroll in a chronic care–management scheme, how to collect data on these patients, and making it all worth the effort.

Using the electronic health record

First, ensure the electronic health record (EHR) has the new code included in its templates, so that you can bill accordingly. Second, it’s important to use the EHR as the melting pot of information relating to managing the patient’s care. The data required to develop a care plan stems from the record of the patient’s demographics, diagnoses, psychosocial factors, medications, allergies and more. The EHR is also where to look when identifying which patients to enroll, and is where the comprehensive care plan is stored. The comprehensive care plan is a summary of all the various patient assessments such as physical, mental, cognitive, social and environmental assessments, a record of preventative services in place, a medication review with all potential interactions and adherence or self-management of medication, and a list of all staff who support and are involved in the patient’s care (including clinicians, specialists and other services not necessarily based in the coordinating physician’s practice). Using medical scribes to thoroughly capture and efficiently input these data into the EHR will ensure seamless creation of the patient record. The comprehensive care plan should be shared electronically with other treating physicians — and while we all know there are still some issues with interoperability, the electronic care plan must be made available to those involved in the patient’s care, thus requiring an up-to-date and interoperable EHR.

Making changes at the practice level

To effectively implement a comprehensive care plan, changes need to be made beyond just preparing a care plan. These changes lie in the services offered by the practice, perhaps the biggest being having to offer 24/7 access to care-management services. The goal is to let the patient make timely contact with the practice staff who have access to their electronic care plan, so they can immediately address the patient’s needs potentially freeing up physician appointment time. The additional systems that need to be implemented are thoroughly reviewed by CMS here.

In addition, physicians need to identify and enroll the 5% of Medicaid beneficiaries targeted by the program. Patients must provide informed consent to allow billing under code 99490 and to, in effect, join the program. As part of the informed-consent process, be sure to tell patients they will have to make a co-payment which, although minimal, may become an issue to those facing financial constraints.

Reaping the benefits

Although the effort may not seem worth $40 per patient, per month, a recent study examined the financial implications of chronic care management for primary care practices with surprising results. The focus here was on identifying net revenue if other care practitioners delivered care, such as registered nurses. Per enrolled patient, practices could expect around $332 per year per patient, with this figure increasing as the qualification level of care practitioner decreased, with revenue reaching $385 for services delivered by a physician’s assistant. Although nursing time would increase — in this example to 12 hours per week — if only half of all eligible patients were enrolled, the practice would be earning more than $75,000 per full time physician. These financial gains allow for the hiring of a full time registered nurse who could be solely responsible for providing chronic care management services, but only if the minimum number of patients needed are enrolled.

Looking ahead: population-based health care

Introducing chronic care management is one step in the right direction to population health management. What starts as a simple change in billing can drive a change from volume to value, leading to better patient-centered, quality health care — aka accountable care. Although the process may seem challenging at first, setting up chronic care–management systems will lead to improved care for those patients who need it the most, shifting the focus from patients targeting the health care service to the heavy users already in it.

Care Navigators
As healthcare business models evolve, so should care teams.

Patients who are paired with Care Navigators report feeling less anxiety, and an increased ability to self-manage their conditions between visits. And providers report increased job satisfaction from improved efficiency, and knowing their patients have access to care teams, and strategic support.

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