Bringing Care Coordination to Specialty Practices: Principle Care Management August 27, 2020 Presented By: Faith Jones and Kevin Franke

8/27/2020

5110MarylandWay 2745NorthDallasPkwy Suite 200 Suite 100 Brentwood, TN 37027 Dallas, TX 75093 615.309.6053 800.228.0647 www.healthtechs3.com www.gaffeythealthcare.com Bringing Care Coordination to Specialty Practices: Principle Care Management August 27, 2020 Presented By: Faith Jones and Kevin Franke

Nationwide Client Base

Currently provides hospital Preferred vendor to: management, consulting services • California Critical Access and technology to: Hospital Network • Western Healthcare Alliance • Serving community, district, non-profit and Partner with Illinois Critical Critical Access hospitals Access Hospital Network Example Managed Hospital Client: • Vizient Group Purchasing Barrett Hospital and Healthcare in Dillon, Organization MT, Ranked as a Top 100 Critical Access Hospital for 8 years in a row

Example technology and AR services client includes two-hospital NFP system in southeast GA with numerous associated physician practices

1 8/27/2020

Areas of Expertise Strategy – Solutions - Support

Governance & Strategy Finance

• Executive management & leadership development • Performance optimization & margin improvement • Community health needs assessment • Revenue cycle & business office improvement • Lean culture • AR outsourcing

Recruitment Clinical Care &Operations

• Executive and interim recruitment • Continuous survey readiness • CEOs, CFOs, CNOs • Care coordination • VP and Department Directors • Swing bed consulting

Interim Executive Services 4 Staffing Community Hospitals since 1971 HealthTechS3 Design.Build.Optimize High Performance Teams

. The Right Executive – our experience and understanding of your hospital is the key to placing . Our Depth: the right executive We support all positions from middle management and up including clinical managers, HR up to CEO, . Immediate Response – Interim needs are typically CFO, CNO, CIO & Clinic Administration immediate. Our bench strength allows us to find the right executive quickly to provide a seamless . Interim Executive Placement Services: transition “Blue Mountain Hospital District has benefited from . Experience – over 49 years of supporting executives the interim executive placement services & teams in hospitals and healthcare companies of all HealthTech S3 provides. Our current CFO started sizes as an interim placement for BMHD, prior to joining our organization in a permanent capacity. The . Support Services – our business is managing hospitals success with this placement has motivated us to more efficiently. We provide comprehensive support consult Health Tech with two subsequent interim services to all our Interim Executives executive needs.” Derek Daly, CEO BMHD

Retained Contingency Interim Contract © HTS3 2020|

2 8/27/2020

Mentoring/Support Team 5 Every Interim Executive is backed by a support team and mentor who help ensure that the team gets the right results HealthTechS3 Design.Build.Optimize High Performance Teams

Retained Contingency Interim Contract © HTS3 2020|

Instructions for today’s Webinar

You may type a question in the text box if you have a question during the presentation

We will try to cover all of your questions – but if we don’t get to them during the webinar we will follow-up with you by e-mail

You may also send questions after the webinar to our team (contact information is included at the end of the presentation) www.healthtechs3.com The webinar will be recorded and the recording will be available on the HealthTechS3 web site: www.healthtechs3.com

HealthTechS3 hopes that the information contained herein will be informative and helpful on industry topics. However, please note that this information is not intended to be definitive. HealthTechS3 and its affiliates expressly disclaim any and all liability, whatsoever, for any such information and for any use made thereof. HealthTechS3 does not and shall not have any authority to develop substantive billing or coding policies for any hospital, clinic or their respective personnel, and any such final responsibility remains exclusively with the hospital, clinic or their respective personnel. HealthTechS3 recommends that hospitals, clinics, their respective personnel, and all other third party recipients of this information consult original source materials and qualified healthcare regulatory counsel for specific guidance in healthcare reimbursement and regulatory matters.

3 8/27/2020

Today’s Objectives 7

Upon completion of the webinar, the participant will understand: 1. The basic elements of chronic care management 2. The basic elements of principle care management 3. How the two services intersect and complement each other in the primary care and specialty practices

Presenter

Faith Jones began her healthcare career in the US Navy over 35 years ago. She has worked in a variety of roles in clinical practice, education, management, administration, consulting, and healthcare compliance.

Her knowledge and experience span various settings from ambulatory to inpatient to post-acute. In her leadership roles she has been responsible for operational leadership for all clinical functions including multiple nursing specialties, pharmacy, laboratory, imaging, nutrition, therapies, as well as administrative functions related to quality management, case management, medical staff credentialing, staff education, and corporate compliance. Faith M Jones, MSN, RN, NEA-BC Director of Care Coordination and She currently implements care coordination programs focusing on the Medicare population and Lean Consulting teaches care coordination concepts nationally. She also holds a Green Belt in Healthcare and is a Certified Lean Instructor. [email protected] 307-272-2207 © HTS3 2020|

4 8/27/2020

Changing Models 9

“Our goal is to recognize the trend toward practice transformation and overall improved quality of care, while preventing unwanted and unnecessary care”

CMS CFR 11-12-2014

Care Coordination Growth and Development 10

2020: Additional Time allowed for CCM, Expand to Team Based 2019: Team based allow for billing of concurrent Care Documentation, services, Principal Care Chronic Care Management (PCM) AWV 2011 2017: Complex Remote CCM, Behavior Physiological Health Integration, Monitoring Collaborative Care (CCRPM) 2016: Chronic Management Care 2018: RHC and Management for FQHC Care RHCs and FQHCs Management and and Advance the Diabetes 2013/2015: Care Planning Prevention Program TCM / CCM Care Management © HTS3 2020|

5 8/27/2020

Elements of Chronic Care Management 11

Practice Eligibility Patient Eligibility • Qualified EMR • Medicare Patient • Availability of electronic • Two or more chronic conditions communication with patient and care expected to last at least 12 months or giver until the death of the patient • Collaboration and communication • At significant risk of death, acute with community resources & referrals exacerbation, decompensation, or • After hours coverage functional decline without management • Care Plan Access • Patient Consent • Primary Care Provider supervision of • CCM initiated by the primary care clinical staff provider • Documentation of at least 20 minutes per calendar month spent coordinating

Presenter

Kevin Franke has over 25 years of health care experience including serving as the director of clinical operations and nursing, quality assurance and improvement, infection control, patient safety and risk management. In addition to working in various healthcare settings, he has also worked as a Quality Improvement Specialist with Mountain Pacific Quality Health, the quality improvement organization (QIO) serving Montana, Wyoming, Alaska, and Hawaii. While working for the QIO, he was the project lead in Wyoming responsible for integrating Care for Populations & Communities Initiative. This initiative centered on the Medicare population and all of the care coordination elements related to ensuring Kevin Franke, BSN that our Medicare patients receive the care they need and the ability to stay in their Owner Care Partner, LLC home and community as long as they desire. [email protected]

6 8/27/2020

Principal Care Management: Care Coordination For Specialty Practices

August 27, 2020

Partnership “People with chronic conditions are getting services, but those services are not for necessarily in sync with one another, Solution ………….to maintain health and A Project of Johns Hopkins University and The Robert Wood Johnson Foundation functioning.” © 2008 Partnership for Solutions

7 8/27/2020

Principal Care Management (PCM)

Designed to address those patients who have “significant resources involved in care management for a single high-risk disease or complex chronic condition”

“Although we did not propose any restrictions on the specialties that could bill for PCM, we expect that most of CMS these services will be billed by specialists who are focused INTENT on managing patients with a single complex chronic condition requiring substantial care management.”

Vol. 84, No. 221/Friday, November 15, 2019/Rules and Regulations p.62692

8 8/27/2020

“We anticipate that in the majority of instances, PCM services will be billed when a single condition is of such CMS complexity that it cannot be managed as effectively in the primary care setting, and instead requires INTENT management by another, more specialized, practitioner.”

Vol. 84, No. 221/Friday, November 15, 2019/Rules and Regulations p.62692

People with serious and/or This is a complicated medical needs will need Team care service from many different medical professionals (and care Approach givers) in multiple settings.

9 8/27/2020

Rheumatology, 1.5

35 Endocrinology, 1.9

Nephrology, 2.2 2018 30 Hema-Oncology, 2.3 25 Medicare Pulmonary Disease, 3.5 20 33.6 Neurology, 3.7 Millions

Physician 15

Cardiology, 11.5 Specialty 10

Utilization 5

0 Beneficiary Utilization Specialty

Cardiology Neurology Pulmonary Disease Hema-Oncology Nephrology Endocrinology Rheumatology

SOURCE: Centers for Medicare & Medicaid Services, Office of Enterprise Data and Analytics, CMS Chronic Conditions Data Warehouse

Services per Person with Specialty Utilization

Rheumatology 6.14

Endocrinology 4.11

Nephrology 7.54

Hema-Oncology 11.49

Pulmonary Disease 4.56

Neurology 3.18

Cardiology 5.18

0 2 4Per year 6 8 10 12

Cardiology Neurology Pulmonary Disease Hema-Oncology Nephrology Endocrinology Rheumatology SOURCE: Centers for Medicare & Medicaid Services, Office of Enterprise Data and Analytics, CMS Chronic Conditions Data Warehouse 2018 Medicare Physician Specialty Utilization

10 8/27/2020

Practice Eligibility

Elements  Qualified EMR of  Availability of electronic communication with patient Principal Care and care giver  Collaboration and communication with community Management resources & referrals (PCM)  After hours coverage  Care Plan Access  Provider supervision of clinical staff

Patient Eligibility

Elements  Medicare Patient of  One serious chronic condition  Condition will typically be expected to last between 3 Principal Care months and 1 year or until the death of the patient Management  May have led to a recent hospitalization and or place the patient at significant risk of death, acute (PCM) exacerbation/decompensation or functional decline  Patient Consent  PCM initiated by the provider

11 8/27/2020

Two key differences:

 Care Plan: PCM requires a “disease-specific” care plan vs. CCM’s comprehensive care plan PCM (Principal Care Management)  Documentation: PCM requires that communication/care vs coordination “between all practitioners furnishing care to the beneficiary… be documented by the practitioner billing for PCM in the patient’s medical record.” CCM (Chronic Care Management)

federalregister.gov/2019-24086-page 420

Chronic Care Management Principal Care Management

Time Requirement (services furnished by clinical staff under 20 minutes/month 30 minutes/month general supervision) Number of Chronic Conditions 2 or more 1 PCM Billing Practitioner (most cases) Primary care provider Specialist (Principal Care Management) Manage disease-specific Scope Manage total patient care care vs General need for care Exacerbation of condition Likely Utilization coordination, or hospitalization communication CCM Shorter-term, until (Chronic Care Management) Intended Length of Time Longer-term, as needed condition is stabilized

12 8/27/2020

PCM Summary

Centers for Medicare & Medicaid Services 42 CFR parts 403, 409, 410, 411, 414, 415, 416, 418, 424, 425, 489, and 498 Page 424

 Ensure that all patients understand the Principal Care Management elements  The right to stop services  Medicare Part B – cost sharing Consent  Signed and easily accessible in EHR; copy to the patient  Consent need only be obtained once  Patient has had to be seen by the provider with in the last 12 months.

13 8/27/2020

Disease  The care plan is a ‘living document’ Specific Care  Disease specific  Plan is in the medical record and available within and Plan and Care outside of the practice Management  Copy of the care plan is given to the patient/caregiver

Home- and  Community-based clinical service providers Community-  Social determinants of health Based Care  Functional Deficits Coordination

14 8/27/2020

 Ongoing communication and care coordination between all practitioners furnishing care to the beneficiary must be documented in the billing practitioner's patient’s medical record. Enhanced  Management of transitions in care and referrals Communication  Accurate documentation and coding are indispensable for proper patient care as well as for getting reimbursed for services provided

Comprehensive care management services for a single high- risk disease, e.g. Principal Care Management, at least 30 minutes of physician or other qualified health care professional time per calendar month with the following elements:

HCPCS  One complex chronic condition lasting at least 3 G2064 months, which is the focus of the care plan;  The condition is of sufficient severity to place patient at risk of hospitalization or have been the cause of a $78.68 recent hospitalization;  The condition requires development or revision of disease-specific care plan;

 The condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities.

15 8/27/2020

Comprehensive care management for a single high-risk disease services e.g. Principal Care Management, at least 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month with the following elements:

HCPCS  One complex chronic condition lasting at least 3 G2065 months, which is the focus of the care plan;  The condition is of sufficient severity to place a patient at risk of hospitalization or have been cause of a $39.70 recent hospitalization;  The condition requires development or revision of a disease-specific care plan;

 The condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities.

HCPCS G2065 OR PCM Billing HCPCS G2064

Cannot bill both codes for the same patient in the same month

16 8/27/2020

FQHCs and RHCs not eligible to bill PCM – CMS stated in the Final Rule that it will consider adding PCM to HCPCS code G0511, the modifier for care FQHC/RHC management services, in the future; however, it has not done so in the Final Rule, and therefore the PCM codes are not available to FQHCs and RHCs.

• Must have patient consent / agreement for the service • Must be ordered by a Provider • For specific reason Chronic Care • Treatment plan • Device used must meet the FDA definition of Remote Medical device • …”intended for use in the diagnosis of Physiologic disease or other conditions, or in the cure, mitigation, treatment, or prevention of Monitoring disease…” • Data must be wirelessly synced where it can be evaluated • Device must be supplied for at least 16 days to be applied to the billing period

17 8/27/2020

 CPT 99457 Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month.  CPT 99458 Chronic Care Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in Remote a calendar month requiring interactive communication with the Physiologic patient/caregiver during the month; additional 20 minutes  CPT 99453 Monitoring Remote monitoring of physiologic parameters (e.g., weight, blood pressure, pulse oximetry, etc) initial; setup and patient education on use of equipment.  CPT 99454 Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s)or programmed alert(s) transmission, each 30 days.

Chronic Care Remote Physiologic Monitoring Remote (RPM) can be billed concurrently with principal care management as long as Physiologic the time is not counted twice. Monitoring

18 8/27/2020

Mrs. Jones is a 66-year-old patient with diabetes and Real cardiovascular disease. She is a patient of Dr. Primary. Dr. Life Primary has been managing Mrs. Jones’s diabetes and CVD for the past 5 years. She is enrolled in the CCM Scenario program with Dr. Primary.

Beth, the Care Coordinator for Dr. Primary had contacted Mrs. Jones, as she normally does every month, to ask her how she is progressing with their intervention from her care plan to walk everyday to increase her stamina. Her The story goal is she wants to be able to dance at her granddaughter's wedding. Mrs. Jones reported that she continues… had to stop walking yesterday because she become extremely short of breath and she felt pressure in her chest. Mrs. Jones said that it isn’t any better this morning , but maybe a little worse. Beth asked that she get to the Emergency Department at the local hospital.

19 8/27/2020

Mrs. Jones was admitted with ST elevation with SOB and CP. A catherization was performed with stent placement. At discharge the next day, Beth, Dr. Primary’s Care The story Coordinator, contacted Mrs. Jones and spoke with her discharge nurse. Mrs. Jones was to follow-up with the continues… cardiologist at the end of the month. Beth scheduled Mrs. Jones with Dr. Primary in 7 days and followed-up to make sure the appointment with Dr. Cardiology was scheduled as well.

Mrs. Jones had her appointment with Dr. Primary. Beth made a point to see Mrs. Jones and said that she will The story follow-up with her after her appointment with the continues… cardiologist, but to call if she had any concerns or problems. The next week, Mrs. Jones had her appointment with Dr. Cardiology.

20 8/27/2020

Dr. Cardiology told Mrs. Jones that her heart looked good and that her incision in her groin healed up just fine. Dr. Cardiology did tell Mrs. Jones that she did have a mild heart attack and would need to make some changes in The story her life and the she would need to come back and see continues… him in 3 months. Dr. Cardiology told Mrs. Jones “we have a program here that I want you to be apart of. It is specifically for your heart disease. I will have Sarah, my Care Coordinator, come in and talk with you about it.”

Mrs. Jones stated to Sarah that this sounds just like the program at Dr. Primary’s office. Sarah said it is, but we will be concentrating on just your heart disease and that she would be in close contact with Beth, her Care The story Coordinator at Dr. Primary’s office. “Also Mrs. Jones. In the hospital your blood pressures continues… were running high and they were high at the appointment today. Dr. Cardiology would like me to send you home with a monitor that will automatically send the readings to me. It will help him determine what he might need to do to help get those numbers down.”

21 8/27/2020

Dr. Primary Dr. Cardiology

 TCM ------$247  PCM ------$40  G2065 “Team”  99496  CCM ------$42 - $116  RPM (setup)--- $19 Care  99491  99453 Management  G2058  RPM (device)-- $62  99454  Com CCM---- $92 Plus  99487  RPM ------$52 Plus  99457  99489  99458

Sarah has informed Beth the plans for the Remote Again…. Physiological Monitoring for Mrs. Jones. Beth and Sarah will collaborate when reaching out to Mrs. Jones. the story Beth with Dr. Primary reached later in the month to Mrs. continues… Jones. Mrs. Jones stated that her blood sugars are really spiking……………. Dr. Endocrinology ?

22 8/27/2020

“In my experience there is far less Jane Brock MD, substandard clinical care than there is MSPH unreliable care delivery process. Care delivery Quality Innovation Network infrastructure is almost always the issue in National Coordinating Center care coordination gaps.”

Questions?

Kevin Franke, BSN [email protected] (307) 267-5061

23 8/27/2020

Online Courses for Care Coordination 47

Scheduled Courses and Self-Paced Courses All provide Continuing Education Credit Check out website: https://www.healthtechs3.com/certificate-courses/

Current listing:

Community Health Needs Assessments: More Than a Regulation – A Tool to Assist in Delivering The Role of a Rural Hospital’s Board in a Time of Crisis: How the Hospital Board and Care CEO Ensure an Organization’s Success During COVID-19 Date : July 14, 2020 Time : 12pm CST Date : September 4, 2020 Time : 12pm CST Presenter : Julie Haynes, Strategic Planning Consultant Speaker : Peter Goodspeed, Vice President of Executive Search Presenter : Faith M Jones, MSN, RN, NEA-BC Director of Care Coordination and Lean Consulting https://bit.ly/38fXyOI https://bit.ly/2ZqPgzr Rural Healthcare Challenges in Times of Change Ask Carolyn – Your Swing Bed Questions Answered Date : September 11, 2020 Time : 12pm CST Date : July 24, 2020 Time : 12pm CST Host : Carolyn St.Charles, RN, BSN, MBA – Chief Clinical Officer Speaker : Carolyn St.Charles, RN, BSN, MBA – Chief Clinical Officer Presenters : Rhonda Mason, Cobre Valley Regional Medical Center; Margie Molitor, Hot https://bit.ly/2Zw55os Springs County Memorial Hospital; Deborah Morris, Blue Mountain Hospital; Terry Odom, Powell Valley Healthcare https://bit.ly/38gZWEI More Than a Plan: Keeping Your Physical Environment of Care Safe for Patients, Staff and Visitors Date : August 7, 2020 Time : 12pm CST Innovating Care Models for Opioid Use Disorder Patients Host : Carolyn St.Charles, RN, BSN, MBA – Chief Clinical Officer Date : September 24, 2020 Time : 12pm CST Speaker : Dr. Frank Mineo, FACHE, CEM, CHSP, CHEP Presenter : Rebecca Morgan, CEO, Spark Creative https://bit.ly/3eRC5ho Presenter : Faith M Jones, MSN, RN, NEA-BC - Director of Care Coordination and Lean Consulting Effective Communication in Healthcare https://bit.ly/2ZyjQaC Date : August 14, 2020 Time : 12pm CST Host : Carolyn St.Charles, RN, BSN, MBA – Chief Clinical Officer The Hospital’s Role in Getting the Right Interim Leader – What Does it Need to Know? Speaker : John A. Coldsmith, DNP, MSN, RN, NEA-BC Date : September 25, 2020 Time : 12pm CST https://bit.ly/2AiNkAq Speaker : Mike Lieb, FACHE – Vice President https://bit.ly/2BvqXZ7 Bringing Care Coordination to Specialty Practices: Principle Care Management Date : August 27, 2020 Time : 12pm CST An Introduction to Our Cloud-Based Optimum Financial Statement Toolkit (OFST) Speaker : Kevin Franke, BSN, Principal Consultant, Care Partner, LLC Date : September 30, 2020 Time : 12pm CST Facilitator : Faith M Jones, MSN, RN, NEA-BC - Director of Care Coordination and Lean Consulting, Presenter : John Freeman, Associate Vice President HealthTechS3 Presenter : Kevin Stringer, Associate Vice President https://bit.ly/3dQiaya https://bit.ly/2YPQG7G

24 8/27/2020

THANK YOU

We hope this information has been helpful! Please contact us if you would like to discuss bringing care coordination to your primary and or specialty practices, or if you have questions about the presentation HealthTechS3 Kevin Franke, BSN Faith Jones 5110 Maryland Way, Suite 200 Owner Director of Care Brentwood, TN 37027 Care Partner, LLC Coordination & Website: www.healthtechs3.com Lean Consulting [email protected] and [email protected] © HTS3 2020|