A Pilot to Implement Chronic Care Management Services at an Academic Medical Center

Abstract

Objective: Chronic Care Management (CCM) for patients requires care coordination. Our aim was to describe a pilot to implement CCM services within our house call program. We aimed to identify processes and verify reimbursement. Design: Pilot study and retrospective review of patients participating in CCM. Setting and Participants: Non-face-to face delivery of CCM services at an academic center. Sixty-five and over with two or more chronic conditions expected to last at least 12 month or until the death of the patient from July 15th, 2019 to June 30, 2020. Methods: We identified patients using a registry. If consent given, a care plan was documented in the chart and shared with the patient. The nurse would then call the patient during the month to follow up on the care plan. Results: Twenty-three patients participated. Mean age was 82 years. Majority were white (67%). One thousand sixty-six dollars ($1,066) were collected for CCM. Co-pay for traditional MCR was $8.47. Most common chronic disease diagnoses were hypertension, congestive heart failure, chronic kidney disease, dementia with behavior and psychological disturbance, and type 2 diabetes mellitus. Conclusion and Implications: CCM services offer additional revenue source for practices that provide care coordination for chronic disease management.

Introduction

Medicare (MCR) beneficiaries with multiple (>2) chronic conditions (MCC) pose challenges to the healthcare system, including coordination of care and cost containment (Lochner et al., 2013; MEDPAC, 2022). People aged 65 and over represent about 83% of the Medicare population (Centers for Medicare and Medicaid Services, 2012). Two-thirds have at least two or more chronic conditions (National Center for Chronic Disease Prevention and Health Promotion (U.S.). Division of Adult and Community Health, 2011; Centers for Medicare and Medicaid Services, 2012). Fourteen percent of MCR beneficiaries suffer from six or more conditions and account for almost half of total MCR spending (Lochner et al., 2013; Centers for Medicare and Medicaid Services, 2012; MEDPAC, 2022). The Centers for Medicare & Medicaid Services (CMS) recognize Chronic Care Management (CCM) as a critical component of primary care that contributes to better health and care for these individuals (Network^® TML, 2019). Wagener et al. define the CCM model to redesign primary care to address the needs of patients with MCC. Based on this model, CCM focuses on health care delivery using six components: (1) organizational/system support, (2) clinical informatics systems, (3) delivery system design, (4) decision support, (5) self-management support, and (6) community resources (Bodenheimer et al., 2002). Implementation of these components have shown to reduce health care costs (Davy et al., 2015). Studies have found that the risk of hospitalization is higher with inadequate care, poor patient adherence to medications and self-care regimens, and poor communication among providers who take care of patients with MCC (Bodenheimer et al., 2002; Bott et al., 2009; Lorig et al., 1999; Wheeler et al., 2003). In 2015, MCR began paying for CCM services, under the MCR Physician Fee Schedule (PFS). These are non-face to face services, not provided by the billing practitioner, but rather the clinical staff working under the direction of the billing practitioner. Per MCR guidelines, a designated representative(s) will help coordinate patient care, following the care plan created by the provider. Services provided include documentation of patient health information, maintaining and updating a comprehensive electronic care plan, follow-up during transitions of care, other care management services, and coordinating care.

CMS criteria for reimbursing for CCM for patients includes beneficiaries with two or more chronic conditions expected to last at least 12 months or until the death of the patient. Per MCR “the chronic conditions must place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline” (Network^® TML, 2019). CCM services reimburse providers for providing 24/7 access to care for enrolled patients, coordinating care with outside entities, and monitoring complex care plans. Providers can receive a monthly reimbursement of approximately $40 per beneficiary if they follow specific clinical guidelines, including documenting care plans and spending 20 or more minutes per month with each patient providing long-term CCM services. Providers can expect on average $36 to $41 per patient per month (Bott et al., 2009; Lorig et al., 1999; Network^® TML, 2019; O’Malley et al., 2017; Wheeler et al., 2003). In July 2019, CMS proposed several changes to the physician fee schedule for 2020, which would ease documentation requirements for CCM (CMS News and Media Group, 2019). We implemented the CCM pilot through the Care of the Vulnerable Elderly (COVE), Home-Based Primary Care (HBPC) program at our institute.

Methods

COVE is an academic HBPC program that provides care to about 450 older people in Dallas, Texas. COVE interdisciplinary team is comprised of 1.5 FTE physicians, 2 FTE nurse practitioners (NP), 1 FTE licensed clinical social worker (LCSW), 1 FTE registered nurse (RN), and 1 FTE clinical coordinator. Physicians see all new patients and perform follow-up visits every 3 to 4 months. NPs make visits in between the physician visits, including urgent visits and transition care visits. Mean age of patients is 87, with majority (70%) female. COVE is part of the Southwestern Health Resources (SWHR) Next Generation Accountable Care Organization (ACO). Preliminary health care utilization data suggest that after enrollment, COVE participants had reduction in emergency department visits, hospital admission, readmission, and in skilled nursing facility spending when compared to risk adjusted ACO controls (Jamshed et al., 2020).

Sample and Recruitment

Patients 65 and older were eligible to participate in the CCM pilot if they had two or more chronic conditions expected to last at least 12 months or until the death of the patient. The chronic conditions had to place them at significant risk of death, acute exacerbation/decompensation, or functional decline (CMS News and Media Group, 2019). We excluded patients without patient portal access from the pilot. CMS requires written and/or verbal patient consent for CCM services. For patients with cognitive impairment their health proxy provided this consent.

A health informatics and information resources team within the electronic medical record system (EMR) created an Eligible Patient Report (CCM Registry). The registry identified patients, with the qualifying criteria including primary payer as Medicare and having at least two chronic conditions.

The registry has an inclusion rule logic that created an algorithm. This generated Best Practice Alerts (BPA) in the EMR. BPA alerted the primary care physician for patient’s eligibility for CCM. Physician/NP enrolled patients through in-person or phone discussion. For the pilot, we decided to enroll with written consent. The patient portal generated an enrollment message and consent form for the patient or their proxy to print and sign. Providers could also have the consent signed during the in-person visit. If enrolled over the phone, we mailed the consent form to the patient. A smart phrase documented the consent in the patient chart. Providers gave patients/caregivers a detailed description of CCM, including but not limited to proactive phone call by RN or LCSW, coordination of care, medication reconciliation, and transition care management. Once the care plan was developed it was shared via patient portal. We counseled the patients that they could be responsible for a co-pay, and that they can opt-out of CCM, if not satisfied at any time. Figure 1 summarizes the CCM enrollment pathway.

Figure 1.

CCM enrollment pathway.

Description of Crosswalk—CMS Guidelines

Prior to billing, the EMR team created a crosswalk to design a process for operation and documentation. We used CMS guidelines to create the crosswalk (Tables 1 and 2). Creating the crosswalk was essential to assure that all required components were complete prior to billing.

Table 1.

Scope of Services Required to Bill for CCM.

Requirements	Process
24/7 access to EMR	24/7 clinical services, access to citrix
Continuity of care	Care team assignment, patient care coordination notes
Patient-centered care plan	Longitudinal plan of care
Management of chronic conditions	Patient outreach encounter and disease-specific assessment (Smart Forms)
Management of care transitions	Care coordination note, longitudinal plan of care
Communication with home/community-based clinical services	Referral orders, patient instructions, incorporating community-based services
Caregivers/beneficiary communications	Patient portal, in basket
Informing beneficiary of services	Patient portal communication, in person communication. Identification of patients based off reporting workbench reports.
Documentation in EMR that CCM services were explained/offered, whether beneficiary accepted/denied	Enrollment Smart Form. Paper consent form
Provisioning of the electronic care plan	Longitudinal plan of care in patient portal
Informing beneficiary of the right to revoke agreement to partake in the program	Enrollment Smart Form. Patient info sheet
Informing beneficiary that only one provider can provide these services/charge for these services	Enrollment Smart Form. Paper consent form.

Table 2.

Longitudinal Plan of Care per CMS Requirements for Billing-Crosswalk for the Clinical Components.

Longitudinal plan of care	Problem list
Expected outcome	Within problem list and patient goals
Treatment goals	Patient goals, smart tools (texts, phrases, lists)
Symptom management plan	Longitudinal plan of care, goals, problem list
Planned interventions	Patient goals, smart tools
Medication management	Medication review
List of social services	Patient goals, smart tools
Plan for coordination outside services	Patient goals, smart tools
Review/revise care plan	Patient outreach tracking

CCM Intervention and Training

We formed a CCM-COVE work group, which included members from COVE and EPIC care team, front-end revenue cycle, health informatics, clinical workflow and clinician training analysts, information resources, nursing education, and central administration for project management. The 9-month development phase included monthly workgroup meetings throughout the planning, implementation, and maintenance phases of the project. We identified four areas of CCM as key to success: Developing a CCM Registry, CCM enrollment, CCM Outreach, Requirements for Billing, Demo.

We reviewed the guidelines and recommendations from CMS and EPIC Systems Corporation, for implementing CCM and billing for non-face to face activities. For COVE HBPC pilot we assigned LCSW and RN as the designated CCM representatives. Prior to implementation, COVE champions received 2 h of training for documentation of CCM activities by the health informatics team and the billing and coding representatives. Champions included a physician, a nurse practitioner, registered nurse, and social worker. The training team provided the physician and NP the CMS requirements for CCM, and care plan guidelines along with, fact sheets for CCM services by CMS.

Champion physician identified eligible patients using the BPA during the face-to-face visits. The physician provided the CCM information sheet and the consent form. Patient or proxy were informed that CCM services were available and possible cost-sharing. As per CMS only one practitioner could provide and be paid for CCM services during a calendar month. Patients also had the right to stop CCM services at any time (effective at the end of the calendar month). UT Southwestern Medical Center (UTSW) health informatics team created a tip sheet for providers and staff for documenting CCM activities. We created two routes for CCM documentation. One through the CCM enrolled patients report, the other via a specific “patient outreach” type encounter. Currently, RN and LCSW can document CCM activities in any encounter type.

Outreach

CCM patient report within the EMR has the capacity to sort enrolled patients by upcoming outreach date. This allows care team members to review the patient’s medical history and initiate an outgoing call. Patients enrolled in the CCM program, have a comprehensive care plan documented in the patient’s chart by their clinicians. Providers document the care plan under the “care coordination note” for accessibility and visibility. The RN and/or LCSW contact the patient after enrollment using the “patient outreach” encounter; complete the Smart Form (Figure 2), place orders as necessary, update patient goals, document notes, patient instructions, and follow-up. The form allows CCM staff and providers to document the minutes spent on outreach for the patient. Follow up calls occur weekly until the care plan is completed or ongoing during the enrollment period. Patient could also reach out via phone call or patient portal. Care plans include but are not limited to chronic diseases management, test results, psychosocial needs, medication needs, signs of decompensation of chronic disease, and identification of care gaps. We shared the care plan with the patient/PHI as required by CMS via patient portal or mail. The IDT identifies problem-oriented goals that they can track over time. In the current EMR system, goal types can reference weight, blood pressure, a specific lab component, or a lifestyle habit, such as exercise or diet. Patient goals are for long-term health objectives that help patients manage a chronic disease, prevent future health issues, or maintain an overall higher quality of living.

Figure 2.

Enrollment Smart Form.

Billing

The final step of the implementation of the CCM model was billing. The system automatically bills CPT code 99490 if the patient has accumulated 20 min or more of care in the month and has no exclusionary charges. For the purposes of our pilot, we established the codes listed in Table 3, with their descriptions and 2019 MCR allowable amounts for non-facility work in Dallas County. We chose to start with these two codes for simplicity of monitoring pilot progress and for establishing a CCM program and workflow.

Table 3.

CPT Codes for CCM Billing.

Code	Description	Reimbursement
99490	CCM, clinical staff time 20+ minutes	$42.36
+G0506	Add on code for “extensive assessment and care planning when the consenting practitioner personally performs this work” in addition to the usual effort of the initiating E&M	$63.72
	Additional CCM codes for billing
99491	CCM, MD or APP time, 30+ minutes	$84.24
99487	Complex CCM, clinical staff time 60 min	$93.68
99489	Complex CCM, each additional 30 min	$46.84

At the start of the pilot, three additional codes 99,491, 99,487, and 99,489 were billable. We did not include these in the pilot. Future program plans include documenting and billing for these codes.

Results

At the time of the pilot, 235 patients were eligible for CCM per the registry. Our goal was to enroll 25 patients in the pilot for CCM by June 30, 2020. We enrolled 23 patients from July 1, 2019 to June 30, 2020. All patients had traditional MCR. Four were dual eligible. The average age of the patients was 82 years, with 72% female. Majority of the patients were white (67%). Sixteen patients lived at home with caregivers, five in assisted living facilities and two independently at home. All required assistance in at least one personal care. More than half (55%) of the patients used ambulatory assisted device. Others used at least one durable medical equipment. The most common chronic disease diagnoses for CCM enrollment were hypertension, congestive heart failure, chronic kidney disease, dementia with behavior and psychological disturbance and type 2 diabetes mellitus. Other diagnosis included atrial fibrillation, chronic obstructive pulmonary disease, and major depression. All patients approached agreed to enrolling in CCM. One thousand sixty-six dollars ($1,066) were collected from MCR for CCM services during this pilot. The co-pay for traditional MCR was $8.47 and only one patient had a co-pay. Twenty-two out of the 23 patients had private secondary insurance or Medicaid, which covered the co-pay. Insurance reimbursement amount ranged from $33.21 to $41.68. These collections did not include the billing for time spent beyond 20 min, since that was not available for the pilot study. The focus of the pilot was implementation of the CCM model. We did not assess clinical outcomes for the pilot. We plan to study outcomes once an adequate number of patients have enrolled in CCM. No patient has dis-enrolled from the program to date. Due to the COVID pandemic, we delayed the patient satisfaction survey. COVE provides significant care coordination for its patients. CCM offers reimbursement for the non-face to face efforts of this care coordination.

Discussion

When non-physician staff deliver CCM services, net revenue to practice can increase despite opportunity and staff costs. It is expected that practices could expect approximately $332 per enrolled per year if CCM services were delivered by registered nurses and $372 if delivered by medical assistants. This equates to more than $5,000 of net annual revenue per FTE physician and 12 h of nursing service time per week if 50% of eligible patient enroll. A practice must enroll at least 131 Medicare patients, to recoup the salary and overhead costs of hiring a full-time RN to provide CCM services (Basu et al., 2015). Membership in an ACO can ease that infrastructure cost burden, because the ACO can efficiently provide CCM services through a hub serving multiple practices. Value based contracts allow ACOs to give multiple providers access to the data analytics required to manage patients. Our goal is to enroll all eligible MCR patients who would benefit from CCM services. This would generate revenue for non-face-to-face services for patients with MCC, which will support a full-time RN position, and improve quality of care for our vulnerable patients.

Our program successfully implemented a CCM model of care. The pilot provided a pathway and processes, including collection of revenue for the non-face-to-face services that can financially sustained. The CCM plans for the duration of the pilot did not change. However, the approach allowed the providers and patients to prioritize care goals and create plan around chronic diseases that required more attention. As an example, we implemented CCM for a patient with uncontrolled diabetes and hypertension, who was struggling due to social determinants of health including health literacy. The model allowed a more pro-active and tailored approach to her care. This was received positively by the patients and caregivers. Next steps includes expansion of the program within COVE and to other clinics at UT Southwestern Medical Center. CCM provides improved care by increasing patient connection with their primary team, and possibly reducing unnecessary health care utilization (Schurrer et al., 2017). CCM model has shown that it can improve care for CHF and asthma patient (Asch et al., 2005; Mangione-Smith et al., 2005). Implementation of CCM significantly improves at least some process and outcome measure compared to controls across a variety of disease, including comorbid depression and cancer (Dwight-Johnson et al., 2005). In an evaluation of patient satisfaction conducted by Mathematica policy research, MCR beneficiaries report general satisfaction with CCM services and would recommend it to others. They also conducted a difference-in-difference analysis to study expenditure, service utilization, and quality outcomes over a 6-, 12-, and 18-month period. Engaging in CCM services increased use to community-based services, such as home health and reduced inpatient hospital service, SNF admission, and outpatient services utilization (Schurrer et al., 2017).

Limitations

We were unable to reach our pilot goal of 25 patients. There were logistical barriers to enrolling patients. These included waiting for in person house call visits, and initial limitation of enrollment limited to one champion physician and NP. Despite the education and training, physicians and NPs found it difficult to discuss co-pay for CCM services with the patients thus limiting enrollment initially. CCM enrollment and consent will now become part of the new patient package, thus making it easier for patients to enroll, and providers to initiate conversation. Another limiting factor for enrollment was development of care plan. It was pointed out by the providers that a template would ease the burden of care plan documentation. After the pilot we have created a smart phrase in the EMR for this care plan. Alternatively, it was recommended to use the assessment and plan section as the care plan for CCM that can be shared with the patient. Since the intention of the pilot was to start small, to delineate and address any issues that occur, we decided to make changes, and then educate all team members before offering CCM to future eligible patients.

We faced significant challenges to identify a place for the comprehensive care plan in the EMR. Care plan must be visible to all ancillary staff with ease. We also had difficulty sharing the care plan with patients who did not access to the online patient portal. For the pilot we limited enrollment to patients who had access to the patient portal.

MCR gives minimal guidelines on how to document the care plan. The 2020 PFS gives some guidance on what needs to be included in the care plan. It is unclear if we should address each chronic condition separately, or collectively. Therefore, internal audits will need to continue to assess the eligibility of the care plans for each CCM patients for now. Once approached by providers, consenting for CCM services and billing was not a barrier for our program.

Conclusion and Implications

CCM payment was one of the first broad changes to primary care nationwide by MCR. The financial returns provide incentives to deliver team-based care and utilize non-clinician staff to provide CCM. Many practices find CCM billing to be complicated. We show a pathway for these practices to implement CCM using EMR in an efficient way. CCM can provide a change to develop substantial gross revenue stream by billing 42 to 90 dollars per month per patient for CCM. CCM programs can reduce overall cost and improve quality of patient care, by shifting to a value-based approach that combines robust enrollment of those who would benefit, detailed documentation of billable activities, and a thoughtful care-plan based service (Schurrer et al., 2017).

CCM recognizes the non-face to face work needed to take care of this vulnerable population. It is an opportunity for practices to generate revenue for these “behind-the-scenes” interactions. Billing for CCM can cut practices expenses and boost revenues. CCM services can reduce growth in total monthly expenditure over time and generate revenues whenever a patient receives healthcare services for the specific condition within a month. Practice can also score highly when adopting CCM in the cost category of the Merit-Based Incentive Payment Systems’ (MIPS) performance score. To implement CCM in practices for providing care to patients with multiple chronic conditions, practices will require leadership support and meet minimum requirements. Programs that focus on high-risk patients and those transitioning from hospital and post-acute care, improve quality of care (Zurovac et al., 2017). Patients who understand discharge instructions, have lower hospital admissions and readmissions, and are 30% less likely to be re-admitted or seek care at the ED after discharge (Jack et al., 2009). Care coordination is a requirement for CCM programs. Costs for patients with uncoordinated care are 75% higher than those who receive care coordination (Haney et al., 2012; Yong et al., 2010). Finally, in the Merit-based Incentive Payment System (MIPS) quality performance category, CCM qualifies for 33 measures, including 22 high priority measures (PPRI, 2016). Implementing a CCM program within an organization requires stakeholder support to focus on population health management. COVE had immense support at every level from division to department leadership, and the ACO. CCM services can increase coordination of care, improve patient satisfaction, offer an additional revenue source for providers (O'Malley et al., 2017), and promote patient health outcomes. CCM value-based approach focuses on enrolling patients that would benefit from these services, structured documentation of billable activities, and a delivery system that focuses on patients and caregivers care needs. This allows practices to reduce total cost of care while providing overall value to the patient and their caregivers. Studies need to be conducted evaluate health care utilization outcomes for patients enrolled in CCM.