Transcript Clinical Case Illustrating Chronic Care Management Driven Success

Clinical Case Illustrating
Chronic Care Management
Driven Success:
Home is Where the Heart Is
Kyley Ogard, MSN GNP-C ANP-C
May 18, 2016
Disclosures
Employee of Kindred Health Care
Objectives
• Use the information presented to improve their
care planning practices.
Chronic Care Management:
What is it?
• CMS added a new CPT 99490 effective
January 1, 2015 with a national allowed
amount of $42.60 to cover your provided
chronic care management services to those
eligible.
CCM: What is it?
• CMS requires 20 minutes per calendar month
of documented clinical staff time directed by a
physician or other qualified healthcare
professional
CCM: What is it?
• Patient must have multiple (TWO or more)
chronic conditions expected to last at least
12 months, or until death of patient
• Chronic conditions place patient at
significant risk of death, acute
exacerbation/decompensation, or functional
decline
• A comprehensive plan must be established,
implemented, revised, and monitored.
CMS Elements of Service
• 24/7 access to care
• Continuity of care with designated team
member
• Creation of comprehensive patient-centered
care plan based on assessments of physical,
mental, cognitive, psychosocial, functional, and
environmental assessments
CMS Elements of Service
• Management of chronic conditions
• Management of care transitions
• Coordination with home and community-based
service providers
• Enhanced opportunities for beneficiary and
caregivers to communicate with providers
regarding care
Additional CMS Requirements
• Documented consent
• 20% beneficiary co-payment applies
• Only one Part B provider can be paid for CCM
in one calendar month
• Use a certified EHR
• Cannot bill CPT codes for CPO, TCM, hospice,
and certain ESRD codes same month as CCM
CPT
Case Study: GG
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Feb 2015: consent obtained & created plan of care
93 yo
Lives in ALF
PMH: diastolic CHF, HTN, tachyarrhythmia s/p pacemaker,
Afib, COPD, CKD stage 3, diet controlled DM type II, right
adhesive capsulitis s/p right rotator cuff injury, recurrent
UTIs, functional urinary incontinence with chronic urinary
leakage, fecal incontinence, moderate generalized DJD, gait
ataxia, dysphagia, Parkinsonism, intrarenal hemorrhage,
mild Alzheimer’s dementia
• Face to face visits:
• 2/4/15 chronic disease mgmt COPD exacerbation
• 2/11/15 active mgmt of COPD exacerbation
GG’s initial CCM Plan of Care
•
Chronic Condition #1 CHF
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Chronic Condition# 2 HTN
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Current health care providers: MD, CNP
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Functional status: ambulatory w/ rollator w/ assist x2 w/ gait belt, moderate limitations
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Cognitive/mental health: alert & oriented x 3, mild Alzheimer’s dementia
•
Expected outcome & prognosis: #1 symptom management to decrease exacerbations and promote quality of life and
prevent hospitalizations. #2 stable BP with goal to avoid dizziness and decrease risk of falls. Prognosis: fair
•
Patient’s goals of care: remain at ALF, no hospitalizations, at home death
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Advanced Directives on file: Yes
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Medication Mgmt: At each face to face visit and prn. Medication reconciliation after each transition of care. ALF nurses
administer medications.
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Measurement of treatment goals: BP stable, labs monitored, avoidance of hospitalizations for CHF mgmt
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Symptom management plan: monitor renal fxn and electrolytes, MWF weights w/ ALF LPN to call if gains 2# between
weights or 4# in 7 days, vitals, Rx mgmt, ALF nurses to report SOB/DOE and worsening LE edema to office/on call
provider for prompt intervention
•
Community/Social Support Service Ordered: on site at ALF, POA/dtr very involved
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How services of agencies/specialists will be coordinated: PCP team will coordinate w/ ALF
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Identify individuals responsible for each area above: PCP/CNP/CC/ALF staff
GG
• March 2015: UTI, called to on call provider –
less than 20 min of non face to face time for
month– did not bill CCM
• April 2015: med refills, med changes, labs
• May 2015: med refills, coordination of care
w/ ALF nurses and new orders
• June 2015: med mgmt
• July 2015: on call abnormal lab results, med
refills, UA C&S, Estrace stopped, cipro for
UTI, yeast cystitis
GG
• Aug 2015: UA C&S, coordination of care w/
POA/dtr, incontinence dermatitis tx, med refills
• Sept 2015: on call fell & sent to ED, team
conference, care plan updated
• Oct 2015: med refill, CXR, labs ordered due to
weight gain, edema, pain meds ordered
• Nov 2015: new wound under abdominal pannus,
witnessed fall w/ PT & skin tears, weight gain,
coordination of care w/ urologist for cystitis,
elevated renal indices due to diuresis on labs, calls
to on call, DME paperwork
GG
• Dec 2015: no CCM billed, coordination of care
w/ urologist, addition of acidophilus while on
antibiotics, planning ALF move coordination
with POA, ALF DON and administrator, home
care, ambulette then change in plan of care
• Goals of Care in GG’s own words:
• Code Status: DNRCC
• Never wanted to be hospitalized again
• Wanted to die at home
• Christmas dinner at current ALF
GG
Making It Happen:
• Patient-driven goals of care
• Medication management
• Labs on site
• Needs a Hoyer lift
• Continuity of care team
• Wound care
• Coordinate with receiving ALF, ambulette, &
home care agency
• Anticipatory guidance
Lessons Learned
• Don’t leave money on the table
• Get started on consent now
• Solutions-oriented thinking
• Your existing EHR
• CCM Program
• Hire a CCM manager
• Start documenting time
• Reviewing labs
• Phone messages
• E-prescribing
• Coordinating care with POAs, HHC,
consultants, hospitals, EDs, etc
References
Chronic Care Management Services. Centers for
Medicare and Medicaid Services (online).
Available at: https://www.cms.gov/Outreach
-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/Downloads/ChronicCareMan
agement.pdf . Accessed February 16, 2016.
Discussion
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