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Connected Care Toolkit – Chronic Care Management Resources for Health Care Professionals and Communities

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Connected Care Toolkit – Chronic Care Management Resources for Health Care Professionals and Communities CONNECTED CARE TOOLKIT Chronic Care Management Resources for Health Care Professionals and Communities Overview of CCM Chronic care management (CCM) is a critical component of primary care that contributes to better outcomes and higher satisfaction for patients. The Centers for Medicare & Medicaid Services (CMS) recognizes that providing CCM services takes provider time and effort. CMS established separate payment under billing codes for the additional time and resources you spend to provide the between-appointment help many of your Medicare and dual eligible (Medicare and Medicaid) patients need to stay on track with their treatments and plan for better health. CCM codes can be billed for services furnished to patients with two or more chronic conditions who are at significant risk of death, acute exacerbation or decompensation, or functional decline. Two thirds of Medicare beneficiaries have two or more chronic conditions, which means many of your patients can benefit from CCM services, including the help provided between visits. CCM can help you deliver coordinated care to your patients that will improve their health, increase satisfaction with their care, and make care more person-centered. This toolkit includes information for health care professionals, professional and patient organizations, and community groups, including tips for getting started, fact sheets on the requirements for providing CCM in practices, and educational materials to share with patients. What Is CCM? CCM is the care coordination that is outside of the regular office visit for patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation or decompensation, or functional decline. It can be delivered to people with many different types of health conditions. Medicare began paying for CCM services separately under the Physician Fee Schedule (PFS) in 2015. Practitioners may now bill for CCM for a calendar month when at least 20 minutes of non- face-to-face clinical staff time, directed by a physician or other qualified health care professional, is spent on care coordination for a Medicare patient with multiple chronic conditions. This time may be spent on activities to manage and coordinate care for eligible Medicare and dual eligible beneficiaries who have. 2 Ways to Use This Toolkit Thank you for your interest in advancing CCM services! The Connected Care Chronic Care Management Toolkit contains educational materials and resources to raise awareness about the importance of CCM services for Medicare and dual eligible patients with multiple chronic conditions. This toolkit is designed to be used in two ways: 1) as a resource for health care professionals to successfully build out CCM services in their practices and 2) as a tool to educate colleagues, members of professional societies, patients, and advocates about the importance of CCM in improving patient health and satisfaction. If You Are a Health Care Professional If you are a health care professional, this toolkit may be used to support your practice with resources to answer common questions and guide discussions with patients and staff. It also provides educational materials to share with your patients so they can better understand CCM services. If You Are an Organization that serves Patients, Caregivers, Health Care Professionals or the Community In addition, this toolkit provides suggestions for activities, resources, and templates for sharing information about both CCM and the materials CMS has developed to support health care professionals and leaders of community and patient organizations. This includes conversation guides and presentations to share with colleagues and staff, as well as with members of organizations that represent both health care professionals and patients. It also includes template language for sharing information through websites, newsletters, emails, blogs, and social media. 3 CM Information and Tools for Health Care Professionals and Their Patient Making Coordinated Care Happen: Benefits to Your Patients and Practice Thank you for working to implement CCM services in your practice. CCM is a critical component of primary care that contributes to better health and care for patients, and even caregivers. Two thirds of people on Medicare have two or more chronic conditions, which means many of your patients can benefit from CCM services. CCM can help you deliver coordinated care to your patients to improve their health and increase satisfaction with their care. Why Is CCM Important? Patients Benefit from CCM • Your patients will gain a team of dedicated health care professionals who can help them plan for better health and stay on track for good health. Services, such as monthly check-ins and ready access to their care team, improve patient care coordination, including improved communication and management of care transitions, referrals, and follow-ups. • Patients will receive a comprehensive care plan. The plan will help support disease control and health management goals, including physical, mental, cognitive, psychosocial, functional, and environmental factors. Patients may also receive a list of suggested resources and community services. Additionally, patients may be encouraged to keep track of referrals, community support, and educational information. Care plans can also help caregivers who are furnishing unpaid care. • Encouraging patients to use CCM will give them the support they need between visits. Having a regular touch point may help patients think about their health more and engage in their treatment plan, for example, by becoming more conscious of taking medications, managing fall risk, and other self-management tasks. Getting this help may also encourage patients to stay on track and improve adherence to their treatment plan. More frequent communication can also help make patients feel more connected to you and your staff. 4 CCM Supports Your Practice • Improve care coordination. Chronic care management can help improve care coordination and health outcomes, and you will receive payment specifically in support of your provision of care using this approach for a patient when you provide a minimum of 20 minutes of CCM services in a month. Encouraging patients to use CCM services will give them the support they need between visits to your office. • Support patient compliance and help patients feel more connected. Some health care professionals have reported that making CCM services available to their patients has helped to improve their efficiency, improve patient satisfaction and compliance, and decrease hospitalization and emergency department visits. • Sustain and grow your practice. Ongoing care management outside the in-person visit has not always been separately billable in payment, making it difficult for practices to sustain service provision. Offering care management activities CCM can provide you with additional resources to help your practice care for high risk, high needs patients. Read on to find out how your practice can begin to provide and seek separate payment for CCM services. CMS has developed fact sheets and FAQs with information about CCM services and payment: • CCM Services Fact Sheet • Chronic Care Management Services • Chronic Care Management Services Changes for 2017 Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) are also authorized to receive payment for CCM services. See the Chronic Care Management Services in Rural Health Clinics and Federally Qualified Health Centers Frequently Asked Questions for specific information about billing and payment for CCM services. Additional information on CCM in RHCs and FQHCs can be found at https://www.cms.gov/Center/Provider-Type/Rural-Health-Clinics-Center.html, and https://www.cms.gov/Center/Provider-Type/Federally-Qualified-Health-Centers-FQHC- Center.html. 5 Getting Your Practice Started with CCM CCM will help you deliver the coordinated care your patients need and deserve. Offering CCM may enable you to sustain and grow your practice and improve patient satisfaction. The full details for introducing or growing CCM services in your practice, including eligibility, included services, billing requirements, how to spend time, and payment amounts, can be found on the Connected Care Hub. Additional resources can be found on: • CMS Care Management Site • CCM Services FAQs • CCM Services Fact Sheet • Care Coordination Services and • Care Management Physician Fee Payment for RHCs and FQHCs Schedule • RHC & FQHC CCM FAQs • CCM Services Changes for 2017 Eligibility Patients eligible for separately payable CCM services are Medicare fee-for-service and dual eligible (Medicare and Medicaid) beneficiaries with two or more chronic conditions expected to last at least twelve months or until the death of the patient, when those conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline. These are the only diagnostic criteria. Examples of chronic conditions include, but are not limited to, the following: Alzheimer’s disease and related dementias, arthritis, asthma, atrial fibrillation, autism spectrum disorders, cancer, cardiovascular disease, chronic obstructive pulmonary disease, depression, substance use disorders, diabetes, hypertension, and infectious diseases such as HIV/AIDS. CCM services may be billed by*: • Physicians and certain Non-Physician Practitioners (Physician Assistants,
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