Benefits of Care Management Presented By Keisha Sexton

Benefits of Care Management Presented By: Keisha Sexton, BBA; Office Manager Natalie Harter, LMSW; Complex Care Manager Mitzie Hewitt, DO; Medical Director & Clinic Owner

Disclosure The content of this presentation does not relate to any product of a commercial interest. Therefore, there are no relevant financial relationships to disclose.

Northern Pines Health Center, P. C. “Northern Pines Health Center is committed to compassionate, high quality healthcare, while stressing prevention and health education for patients of all ages. ” Northern Pines Health Center is an independent rural health clinic located in Buckley, MI. The clinic offers primary care services to patients of all ages delivered by a healthcare team comprised of: a Physician, Physician Assistant, Nurse Practitioner, Care Manager and 13 administrative and clinical support staff members.

Objectives 1. Define Care Management & its purpose. 2. Identify patients who can benefit from Care Management. 3. Identify sources of reimbursement for Care Management services. 4. Discuss the Care Manager’s role & responsibilities. 5. Learn about the benefits of Care Management from a Provider’s perspective.

What is Care Management? Care management is a set of activities designed to assist patients and their support systems in managing medical conditions and related psychosocial problems more effectively, with the aims of improving patients’ functional health status, enhancing the coordination of care, eliminating the duplication of services, and reducing the need for expensive medical services. Bodenheimer T, Berry-Millett R: Follow the money - Controlling expenditures by improving care for patients needing costly services. New Engl J Med 2009; 361(16): 1521 -1523

Who can benefit from Care Management? 1. Patients who have a new diagnosis of a serious health condition. 2. Patients with multiple chronic conditions such as COPD, Diabetes, Cardiovascular Disease or Asthma. 3. Patients with uncontrolled chronic conditions such as Hypertension or Diabetes. 4. Patients with recent and/or frequent hospital admissions, ER or Urgent Care visits. 5. Patients who struggle with issues related to social determinants of health.

Reimbursement for Care Management Services

State Innovation Model (SIM) üMedicaid Patients üMonthly Patient Lists üSpecified Care Management Codes üRequired benchmarks must be met for specified metrics üQuarterly payments based upon SIM targeted population

Provider Delivered Care Management (PDCM) üBlue Cross Blue Shield üMonthly Patient Lists üPaid on claims for specified codes üIncentive payments if metric benchmarks are met

Priority Health üPriority Health Commercial üHigh-Utilizer reports üPaid on claims for specified codes üIncentive payments if metric benchmarks are met

üMedicare üSpecific patient eligibility requirements: Chronic Care Management (CCM) § (Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, and place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline üG 0511 (paid in addition to the billable rate) § 2018 payment (HCPCS code G 0511) – $62. 28

Care Manager’s Role & Responsibilities

üProvide Health Education üManage Health Problems with Goals to Feel Better üHelp with Transportation Care Manager’s Role üCoordination of Health Care Services üAnswer Questions üProvide Connections to Community Resources üLocate Resources for Housing, Food and Utility Assistance üAssist with Medication Management üAssist with Advanced Directives üAssist with Insurance Coverage

Incorporating Care Management in Your Rural Health Clinic A Provider’s Perspective

Benefits of a Care Manager in the Clinical Setting 1. Providing education and training for patients. 2. Expert in community resources. 3. Identifying obstacles that interfere in patients getting to identified goal. 4. Closing Gaps of care. 5. Great point of contact for patients needing assistance. 6. Billable codes that can help generate additional funding for the clinic. 7. Improve overall patient satisfaction.

How Patients are Identified for Care Management 1. Provider schedules are reviewed by the Care Manager 1 -2 days before to identify patients that qualify for CM. 2. Providers identify needs of a patient during the office visit. 3. Reports are run for specific gaps of care with patient groups that qualify for care management. 4. Reports are run for specific groups of patients that qualify for care management.

The Financial Impact of Having a Care Manager 1. Billable codes that are payed to the Rural Health Clinic. a. Priority Health commercial / Priority Health Medicare b. Blue Cross Blue Shield c. All Medicare (chronic care management) d. Medicaid (SIM) 2. Increased revenues by closing care gaps. a. When providers bill for services to close gaps in medically necessary care, more revenues are captured. b. As care gaps are closed, performance in governmental programs (HEDIS, PCMH, MACRA) and commercial (pay-for performance) contracts are improved and in turn, fee schedules are increased.

Improved Quality of Care for our Patients As providers we want to do a better job of educating our patients but have multiple barriers. 1. TIME!! 2. Financial constraints (especially in Rural Health Clinics) 3. Patients not admitting barriers.

Questions?

Resources: Visit the following resources to learn more about the information discussed in this presentation: • Michigan Care Management Resource Center: https: //micmrc. org/ • State Innovation Model (SIM): http: //www. michigan. gov/mdhhs/0, 5885, 7 -339 -71551_2945_64491 ---, 00. html • Provider Delivered Care Management (PDCM): https: //www. bcbsm. com/providers/value-partnerships/physiciangroup-incentive-prog/models-of-care/provider-delivered-care-management. html • Priority Health: https: //www. priorityhealth. com/ • Care Management Services in Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) FAQ: https: //www. cms. gov/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/FQHC-RHC-FAQs. pdf • Northern Pines Health Center, P. C. : www. northernpineshealthcenter. com