Care Management Programs
From Patient Determinants
Care Management Programs are team-based, patient focused, non-medical interventions programs designed to meet specific needs of patients based on the program's criteria. These programs are integrated with the patient's care plan continuing for either for a duration or as long as the patient meets the criteria. The criteria includes risk scores, episode, health conditions and determinants.
New healthcare reimbursement models attribute patients to primary care physicians and healthcare systems for episodes of care. The following Care Management programs are often provided to patients to improve their overall health and healthcare outcomes. These programs include care plan development, administrative support in booking appointments, finding services, coordinating medical services and reminding patients.
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Contents
Behavioral Health & Primary Care Integration
- Screen patient via Primary Care Physician Offices' Clinical Staff
- Engage patients to ensure followup with Behavioral Health providers
- Collaboration between Primary Care and Behavioral Health to ensure best treatment and patient activation
- January 1, 2017, Medicare began paying clinicians separately for Behavioral Health Integration services. Three of these codes describe services furnished using the Psychiatric Collaborative Care Model (CoCM). (2/2/17)
Collaborative Care Model (CoCM) codes
- Initial 70 minutes (G0502) in calendar month
- Subsequent 60 minutes (G0503) in calendar month
- Additional 30 minutes (G0504) in calendar month
- 20 minutes of Care Management Services (G0507) in calendar month
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Chronic Care Management
- Identify patients with two or more chronic conditions
- Identify patients with behavioral health conditions
- Identify patients with functional limitations
- Chronic Care Plan Development that addresses chronic conditions and determinants
- Regular follow-up with patients to ensure treatment effectiveness and adherence
- Medicare Chronic Care Management Payments and Financial Returns to Primary Care Practices: A Modeling Study (10/20/15)
Chronic Care Management (CCM) codes
- 20 minutes of non-face-to-face care management services per month by clinical staff (CPT 99490)
- Complex CCM – 60 minutes of non-face-to-face care management services per month by clinical staff, moderate to high complexity medical decision making (CPT 99487)
- Complex CCM - Additional 30 minutes in calendar month (CPT 99489)
- Remote Patient Monitoring - collection and interpretation of health data generated by a patient remotely, min 30 minutes (99091)
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Episode Management
- Comprehensive programs for surgeries based on type of surgery (i.e., hip replacement)
- Understand and address patients unique conditions and determinants of health
- Patient Navigators to ensure patients efficiently get through the healthcare system
- 90 day program for patients being discharged from hospital
- Identify episode attributed patient population
- Episode Care Plan Development with clearly defined care goals and outcomes
- Coordinate post discharge medical or support services
- Risk-Proofing the Surgical Episode for Patients (10/31/2014)
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ER Case Management
- Assess and understand patient risk factors prior to discharging
- Address patients unique conditions and determinants of health prior to discharge
- Coordinate post discharge medical or support services
Exercise & Nutrition
- Diabetes Prevention Program (DPP)
- Diabetes prevention program
- Diabetes management program
- Nutrition Therapy
Health Coaching
This is being involved in managing health and helping with behavior change
- Motivational Interviewing
- Goal setting
- Develop Friendships and Trust
- Assist with behavior change
- Engage with patient to discuss progress and care plan effectiveness
- Prepare patient for upcoming physician visits or tests
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High Need High Cost
- Defined as patients that are the 5% of healthcare service spending
- Address health conditions and determinants of health
- Assign a nurse, social worker, pharmacist and health coach to patients as required
- Care Plan Development with clearly defined care goals and outcomes
- Designing a High-Performing Health Care System for Patients with Complex Needs: Ten Recommendations for Policymakers (1/19/17)
- Playbook: Better Care for People with Complex Needs. - Five foundations partnered with Institute for Healthcare Improvement to develop this resource for health system leaders, payers, and policy makers seeking to learn more about high-need individuals and promising care approaches.
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Home Care
- Address the needs of homebound patients that often skip care or physician visits
- Physician or Nurse practitioner visits to patients in the home
- Regular follow-up by nurse, social work, pharmacist and/or health coach as necessary
- Home Assessments
- Home Visits - Physicians, Therapist, Nurse Practitioner
- Home support services (i.e., cleaning, maintenance, repairs)
- Delivery services
- Other visits (Community Health Worker, Social Worker, Health Coach)
- Other Home Healthcare Services (i.e., services that don't meet reimbursement requirements, 1. Infusion or Wound Care or Therapy, and, 2. unable to physically travel to doctors office, and 3. had a hospital stay of 3 nights or more, and 4. 60 days of prescribes Home health has not been used).
Medical Home
- Annual Wellness Visits - Of the eligible Medicare Beneficiaries in 2014, 14.5% of males and 16.5% of females had an Annual Wellness Visit
- Quality Measures - Address quality measures for attributed primary care physician (PCP) populations
- Medication Reconciliations
- Preventive screenings - per recommendation of the US Preventive Services Task Force
- Coordinate - healthcare services and E Interventions
- Wellness Care Plan Development that wellness and preventive care recommendations
- Care Gaps & Follow-ups - Identify and address gaps in care and followup to ensure actions are taken.
- Educate patient on the dangers of disjointed and uncoordinated care
- High-value primary care providers are the secret to ACO success (8/9/16)
- Reducing ACO Patient Leakage Begins With Education (9/26/13)
- Health Care uses patient loyalty to determine how happy patients are focusing on three things: 1) Promote price transparency. 2) Offer convenient access to care. 3) Improve care coordination (7/14/16)
- Study finds well-designed primary care team can save $1.2M for every 10k patients (10/25/16)
- Geisinger Health System launched Springboard Health, a program that targets both patients' chronic conditions and the community’s overall socioeconomic health. They will address large-scale socioeconomic issues like hunger and housing insecurity. (1/9/17)
Wellness and Preventitive Care codes
- Welcome to Medicare - Annual Wellness Visit - first year only (G0402)
- Annual Wellness Visit - Initial (G0438)
- Annual Wellness Visit - Subsequent (G0439)
Care Planning Codes
- Care Planning - Prolong Evaluation & Management (E&M) before or after patient care, 60 minutes (99358)
- Care Planning - Prolong Evaluation & Management (E&M) before or after patient care, 60 minutes (99359)
- Advanced Care Planning - initial 30 minute discussion of advanced directives by physician/clinical, face-to-face with patient, family (99497)
- Advanced Care Planning - additional 30 minute discussion to 99497 (99498)
- Visit to determine low-dose computed tomography eligibility (G0296)
- Care Plan Development - Comprehensive assessment, care planning by physician/clinical staff for CCM services, if more time than E&M service eligibility (G0506)
Medication Management
- In-home Medicine reconciliation
- Pharmacist support
- Medication Adherence - reminders, electronic pill boxes
- Medicine home delivery
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Palliative Care
Addressing what is most important to the patient to help enable their well-being rather then more aggressive actions or long term preventive therapies.
Transitional Care Management
- Understand and address patients unique conditions and determinants of health
- 90 day program for patients being discharged from hospital
- Identify episode attributed patient population
- Transitional Care Plan Development with clearly defined care goals and outcomes
- Coordinate post discharge medical or support services
