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.
9/1/2017
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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
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