Review Appendix 1F and describe the decision-making process as it relates to documented progress in treatment. What steps should a clinician take when progress is not being made?
EXAMPLE FORMAT:
Case management is an integrated process which evaluates, plans, coordinates, implements, monitors, and assesses the services and options needed to meet the needs of a client. It characterizes communication, advocacy, and resource management and promotes cost-effective and quality outcomes and interventions.
High-risk care management involves intensive, one-on-one services, provided by a nurse or other health worker, to individuals with complex health and social needs. The formal design of a health center care management program can ensure a standardized approach to managing high-risk patients by a care manager.
Value-based care requires health care organizations to better control the clinical and financial risk associated with high-risk patients. High-risk patients, by definition, have multiple health needs often compounded by complex social and other issues. These patients are at risk for poor health outcomes, inadequate quality of care, and increased costs. The Centers for Medicare and Medicaid Services (CMS) recognizes care management as a critical tool to achieve the Quadruple Aim (better care, better patient and provider experiences, and lower costs).
Key components of care management include: identifying and engaging high-risk individuals, providing a comprehensive assessment, creating an individual care plan, engaging in patient education, monitoring clinical conditions, and coordinating needed services.
CMS requirements for Chronic Care Management (CCM) can be used to frame a care management program targeting high-risk patients. Following these guidelines can help ensure that the care management program, designed to improve patient care and outcomes, can also generate revenue.
CARE MANAGEMENT STEPS:
This Action Guide outlines a set of steps that health centers can take to build a care management program for high-risk patients.
Identify or Hire a Care Manager: Identify staff to serve as the central point of contact for a panel of high-risk patients. These professionals develop, coordinate, and manage the individual care plans of each patient in their panel. An RN often serves in this role.
Identify High-Risk Patients: See the Risk Stratification Action Guide.
Define Care Manager – Care Team Interface: Define how, when, and where the care management program is integrated with the patient’s primary care team.
Define the Services Provided as Part of Care Management: Create a care management program for high-risk patients that is modeled after CMS’s reimbursable CCM services.
Enroll Patients in Care Management: Establish processes to refer, introduce, and onboard patients into care management.
Create Individualized Care Plans: Develop and document personalized care plans by the care manager, in collaboration with the provider and patient.
Enhance and Expand Partnerships: Establish relationships with a continuum of providers and other partners in the community for the referral and care of patients’ health, social, and related needs.
Document and Bill for Care Management: Utilize the existing EHR care plan template, or create another, to document all billable care management services. Use applicable diagnosis codes for billing.
Graduate Patients from Care Management: Establish a process for patients to move out of high- risk care management as they reach care plan goals and return to routine care and follow-up.
Measure Outcomes: Track care management program effectiveness, including performance on UDS measures, and the extent to which patients reach care plan goals.
The level of services
A care management program for high-risk patients should ensure comprehensive care plans that support chronic disease and prevention needs, as well as mental, social, and environmental factors. A provider who can furnish a comprehensive Evaluation and Management (E/M) visit, Annual Wellness Visit (AWV), or Initial Preventive Physical Exam (IPPE) determines whether or not a patient is eligible for CMS reimbursement for CCM services. CCM payments cover the management of chronic illnesses for Medicare and dual-eligible patients. It does not cover time spent on acute care services. CCM reimburses activities not typically furnished face-to-face, including telephone communication, the review of medical records and test results, and the coordination and exchange of health information with other providers. CCM also includes activities such as patient education and motivational counseling (Value Transformation Framework Action Guide, 2019).
Reference
Value Transformation Framework Action Guide. (2019, July). CARE MANAGEMENT. National Association of Community Health Centers. https://www.nachc.org/wp-content/uploads/2019/03/Care-Management-Action-Guide-Mar-2019.pdf.
