Connected Care: What Nurses Should Know About Chronic Care Management Webinar

>>Monique LaRocque:
Good afternoon. Thank you for joining
the Connected Care: What Nurses
Should Know About, Chronic Care Management, presented by the Centers
for Medicare and Medicaid Services,
the Health Resources and Services
Administration, as the National
Association of Hispanic Nurses. We have a few logistical
reminders for you. This webinar
is being recorded, and we will also make the
presentation available after this webinar. This will be an
interactive discussion, so I want your input. There will be time
after the presentation for questions
and discussion. We also believe that your
feedback is important, and so after
this presentation we will have
a few questions for you to answer to help
us understand your needs, how we can
better serve you, and also to learn
more about what your interests are. There will be
a Q&A period. Feel free
to share questions and comments in
the chat window, which is on the right
side of your screen. You can do this throughout
the presentation. Towards the end
of our discussion, we will have
a Q&A period, where you’ll hear from
many of our speakers. This presentation
is also closed-captioned. You can access
real-time transcription of this event. For technical assistance, please contact Go to
Webinar at 855-352-9002. We’ll also be monitoring
the chat window to see if there’s anything
we can do to help you. With that, I’d like to do
a quick overview of our agenda for today. We will be
discussing the burden of chronic diseases, going into more detail
about chronic care management services, and then talking
about Connected Care, and the resources
to support you in your community. We’ll then have
a question and answer session. I’m delighted
that we have some fantastic speakers
here today. We will hear from
Anabell Castro-Thompson, President of
the National Association of Hispanic Nurses; Michelle Oswald,
Program Manager, Connected Care Campaign at the CMS Office
of Minority Health. We’ll also hear
from the field — Lauren Fields, Chief Coordinated
Care Officer, from the AR Care,
Kentucky Care. Allison Castleman will
also be speaking with us, and she is
the Project Director and Community
Health Coordinator at the Paris Henry County
Healthcare Foundation. We’ll also hear
from Beth Chalick-Kaplan. She’s at CMS, Office of the Regional
Administrator. And my name
is Monique LaRocque. And now, I present
to you a brief discussion on the burden
of chronic disease in the United States.>>Anabell Castro-Thompson:
Thank you. My name is Annabelle
Castro-Thompson. I am President of
the National Association of Hispanic Nurses. I am a nurse practitioner
by profession, with extensive expertise
in integrating concepts of care related
to access to care and cultural competence
in healthcare delivery. And so,
it is my privilege to be part
of this webinar, and to tell you
a little bit, give you
a broad overview, of chronic diseases, and then narrow
on specifics of the Hispanic community to give you
a greater sense of what this webinar
is trying to accomplish. And so, very well. A little bit about
chronic disease burden in the United States. According to the Centers
of Disease Control and Prevention, about half of the adults
in the United States have one or more chronic
health conditions. And this may
be conditions such as arthritis, heart disease
and diabetes. As we know, chronic
disease is prevalent among Medicare
beneficiaries, with two-thirds of
beneficiaries having two or more chronic
conditions. And having multiple
chronic conditions increases a person’s risk for poor
healthcare outcomes, including mortality
and functional decline. And this oftentimes leads to an increase
in healthcare spending, and not necessarily
correlated with the best outcomes. Nearly one
in five Americans live in rural communities
across the United States, and therefore they face very unique
healthcare challenges. In particular,
this is demonstrated in access to care, both in terms
of resources and access to clinicians. It also translates
to a higher burden of chronic conditions, and a larger percentage
of uninsured populations. Next slide. The Hispanic community is the fastest
-growing demographic in the United States, and therefore it is
an important market to focus on. As we engage in healthcare
transformation, we institute
care coordination, and improve our
healthcare management. Hispanic Medicare
beneficiaries have increased prevalence and incidents of diseases
such as hypertension, diabetes,
and depression, as compared
to non-Hispanic whites. In 2014, a study by Medicare
also documented disparities
in the medical management of common conditions such as blood
pressure management, hyper-cholestoremia, and hemoglobin A1C
levels. You can view
the statistics and the disparities within the body
of this slide. Next slide, please. From a Hispanic
perspective, care delivered is not
always care received. As a result, Hispanic
Medicare beneficiaries report more difficulty and dissatisfaction with the healthcare
system they receive. Hispanics have
increased reporting of not having
a usual source of care, so they lack
a medical home. They have trouble
getting the care they need at the time
they need it. they delay seeking
care due to costs, and lack of affordability
in our healthcare system, and they report being
dissatisfied or very with the quality
of care. Another study
of 260,000 Medicare beneficiaries shows that Hispanic
participants report more often lacking medical records, relevant information
about their care, and their doctor
does not have the pertinent
information. They experience greater
difficulty getting timely follow-up
on test results, and they receive
less help managing their disease. One conclusion
is care coordination and the use
of care manager and care coordinator
is a key strategy, that has the potential
to improve the effectiveness,
the safety, and the efficiency
of the healthcare system. Moreover, culturally effective
and well-organized and targeted care
coordination programs have been shown
to reduce unnecessary acute care utilization, and improve
healthcare outcomes. When possible, these programs
should be implemented as an overall strategy for treating
the Hispanic community. Next slide. Thank you. The National Association
of Hispanic Nurses is committed
to providing access to educational,
professional, and economic
opportunities for Hispanic nurses. We are committed
to improving diversity in the profession, so that we mirror the
population that we serve. In addition,
NAHN is focused on improving
healthcare delivery to our communities. NAHN strongly advocates for a more affordable,
accessible, and equitable healthcare
system for all. Again,
I’d like to welcome everyone to this webinar, and I invite you
to visit our website for the National
Association of Hispanic Nurses for more information on
our specific initiatives. Thank you.>>Monique LaRocque:
Thank you, Anabell. And now we’ll
from Michelle Oswald, of the CMS Office
of Minority Health.>>Michelle Oswald:
Thanks, Monique. And thank you, Anabell, for that
important information on chronic disease burden among Hispanics
in the U.S. We really do appreciate
this collaboration today with CMS, HRSA,
as well as the National Association
of Hispanic Nurses. And good afternoon,
everyone. So, today, I’m going
to provide you with an overview
of chronic care management services for
Medicare beneficiaries, as well as our new
Connected Care campaign. So, I’m sure
that many of you on this call
may be familiar with chronic care
management services, but as background,
chronic care management is defined as services
provided by a physician or non-physician
practitioner, and their clinical staff, per calendar month
for patients with multiple
chronic conditions. These are timed services of at least
20 minutes per month, and are typically
non-face-to-face care
coordination services such as monthly phone
check-ins with a patient, managing referrals
to other clinicians, or reviewing medical
records or test results. CCM is person-centered, and requires
more centralized management
of patient needs, and coordination
among practitioners and providers. Next slide, please. In 2015, Medicare began
paying separately under the Medicare
physician fee schedule for CCM services furnished to Medicare
patients living with two or more chronic
conditions. CMS first established
payment for CPT code 99490, to pay for at least
20 minutes of clinical staff
time directed by a physician
or other qualified healthcare professional,
per calendar month. Under CCM,
patients receive a comprehensive
care plan, and 20 minutes a month
or more of their dedicated medical
professional’s time, for activities outside of their regular
office visits, such as phone check-ins, and the ability
to reach someone from their care team
24/7, when they have
an urgent need. There are other
requirements to bill for CCM, and you can find
that information on the CMS care management page with the website
listed here. If you go to, and type in
care management in the search engine, you’ll be able to come up
with this page with the frequently-asked
questions and fact sheets. Next slide, please.
CMS has been working diligently
to make rule changes that enable separate
payment for complex and time-intensive
chronic care management services. CMS has also been working to significantly reduce
the administrative burden by improving alignment
with coding language, a simplified
patient consent, and reduced
documentation rules. So, in response
to feedback from healthcare
professionals across the country, CMS added additional
billing codes and an add-on code
in January 2017, so clinicians
could receive payment for spending
additional time on more complex patients. Next slide, please. Here’s a snapshot
of the latest CCM codes, as well as
the clinical staff time that is required to bill
for these codes. The codes that you use
will be dependent on how complex
a patient’s needs are, and the amount
of clinical staff time being spent
on the patient. Next slide, please. I want to point out
that rural health clinics and Federally Qualified
Health Centers are also eligible to bill
and receive payment for chronic care
management services when using CPT
code 99490, or with other
payable services on an RHC or FQHC claim. So, there is
an MLN matters that addresses
CCM services for RHCs and FQHCs if you need
additional information. To search that
on the MLN page, it’s number MM, as in Mary Mary, 9234. That’s MM9234. Next slide, please.
Next slide. This past spring, the Centers for Medicare
and Medicaid Services, along with HRSA’s
Federal Office of Rural Health Policy, launched Connected Care, a chronic care
management campaign. This is a national
public education campaign that seeks to raise
awareness of the benefits of chronic care
management services among healthcare
professionals and patients, specifically
in rural areas and among racial and ethnic minority
populations. Next slide, please. The Connected
Care campaign has two primary
audiences. First, we are targeting
healthcare professionals which include physicians, clinical nurse
specialists, nurse practitioners, certified nurse midwives,
physician assistants, as well as other
clinical staff such as social workers who may be a part of
the care management team. We are also seeking
to reach Medicare and dually eligible
beneficiaries with two or more chronic
health conditions. Through Connected Care, we have placed
a special focus on reaching underserved
rural populations, as well as racial and ethnic minority
populations. Next slide, please. This is
a national campaign, so we are striving
to reach every state, but with targeted
outreach being conducted in
four states, Georgia, New Mexico, Pennsylvania, and Washington State. Using Medicare
claims data, we identified
two markets, one rural county
and one urban area, within each of those
four states, to implement
localized campaigns with the support of CMS and HRSA
regional offices, as well as local
healthcare professionals and grassroots
partnerships. Next slide, please. As you can see here
on this slide, the campaign includes a mix of outreach
approaches, which include patient
and provider education, multiple media
activities, and partnership
development. We have a comprehensive set of
educational materials and resources available on our website
that we’ve developed, and I’ll show you that
in the next slide. Next slide, please. We are excited
about the enhancements that we’ve recently made to our
Connected Care website, that you can see here. It’s Our goal for this site is to be a one-stop shop for chronic
care management, with all of
our new products, as well as links
to chronic care management resources, such as the existing CMS care management page
that I mentioned earlier, as well as links
to our past webinars and information on our upcoming
webinars and events. As part of
the initiative, we are offering
new resources for healthcare
professionals. One of those resources
is a web-based toolkit that is now available
to download as a PDF on our website. Some of the items
that are included in the toolkit are guides to getting
started with CCM, how to talk to staff and patients about
chronic care management, materials that explain
what CCM is, who it’s for,
why it’s beneficial, and how to bill for it. And links
to other resources for you to include the
fact sheets and the FAQs, and other chronic care management
sample materials. We have a testimonial
video that’s coming soon, that will target
healthcare professionals, that will share
the experience of one of our local
clinician champions, and how she was able
to implement chronic care management
in her practice. We also have in-clinic
posters available to display
in doctor’s offices, as well as postcards that can be shared
with patients, that all highlight
chronic care management and the benefits. And we are also
finalizing an animated video
for patients, that explains
the benefits of chronic
care management, that you can also play
in doctor’s offices. And then we have
flyers and posters that are available
to order, that are now on our CMS product ordering
warehouse website. There’s a link to that
page on our website here, so if you got to Go, and go to Resources, you’ll find the link
to be able to go to the CMS product
ordering warehouse page. Next slide, please. Partnerships are vital
to the success of the Connected
Care campaign, with many of you here
on the phone. Support from our partners is critical
to raise awareness about the benefits
of chronic care management services. We are also excited that
we have a partner toolkit that’s available
on our website. The toolkit is web-based, and it’s available
to download as a PDF. It has suggested
activities and information
that you can use, such as drop-in language
for articles, a slide deck template as well as draft
social media posts. So we would love
to hear from you, if you’re interested
in becoming a partner, have specific
chronic care management questions, or if you want
to share with us ways that you are implementing
chronic care management in your practice. You can email us,
the email is listed here, [email protected] Next slide, please. And here are some
takeaways from today, so ways that you can get
started and get involved. We encourage
you to download and order our materials
for your waiting rooms. Visit our Connected
Care hub, our website, and access our healthcare
professional toolkit for more information, and become a partner in the Connected
Care campaign. And if you have
specific questions, we will have
a Q&A session at the end of the call. But if you have
a specific question that’s related
to billing, or maybe a little
more complicated, I encourage you
to email me in the CCM mailbox, [email protected], and that’ll help us
get some time to research
your question, and then be able
to give you the best possible answer. Thank you so much.>>Monique LaRocque:
Thank you, Michelle, that was very helpful. We appreciate
that presentation. We will now hear from
stories from the field, and next up
is Lauren Fields.>>Lauren Fields:
Good afternoon. My name is Lauren Fields, and I’m the Chief
Coordinated Care Officer, and an R.N. for AR-Care
and Kentucky Care, a federally-qualified
healthcare center operating
in rural Arkansas and rural
western Kentucky. Next slide, please. Today, I would like
to speak to you about our chronic
care management program, including our successes and the hurdles
that we are working to overcome
with this program. Next slide, please. We began chronic
care management last November
with only one nurse. Next slide, please. And added five additional RNs and two
registered dietitians in January to expand chronic care management
to all 41 of our clinics. Next slide, please. We focus on five
specific diagnoses for our program,
diabetes, CHS, COPD, depression, and obesity at present. Currently, each educator
has around 75 patients. We hope to reach
full capacity by September
of this year, with each educator
having 200 patients. Next slide, please.
We provide each patient with a designated phone number directly
to the educator from eight to five, and our own call provider
hotline after hours. Each patient that enrolls
is sent a welcome packet and a chronic care
management education book. We also provide
the patient with a magnet for easy access
to our phone number. Each patient has a patient-centered
care plan based on their diagnoses
and their needs. Next slide, please. We have experienced
many successes as well
as a few hardships while providing
chronic care services to our rural population. When I ask the educators for some of their
success stories, they were delighted
to share the following stories
with me. One of the nurses
stated that she was making a monthly call
on one of her patients who has a history
of stroke, and had recent other
difficulties lately in his life. He reported that
he had thoughts of harming himself. The patient said
that he did not feel comfortable
discussing this with his provider
at the time. To make a long
story short, the provider was made
aware of the issue, and actions were taken. The patient now voices that he enjoys
and looks forward to speaking to
the educator each month, because he doesn’t get
out of his house much or have a social life. Sometimes our patients
just need to know that we care about them, and what is happening
in their lives. Next slide, please. Another success story
came from the dietitian, who, while talking
with a patient, noticed that she had
signs of depression. She was able to get her
in with the provider and the patient
was treated for her diagnosis. The dietitian said
the patient texts her to tell her of a
six-pound weight loss. She’s told her
that she had stopped turning to food
when she was depressed, and was now taking
control of her life. Next slide, please. Another success story was of a patient
who had attempted to better her
health numerous times without success. The dietitian stated, I first saw this patient
for weight loss in September
of last year, and then did not see her
again until January. She had no success in
those first few months, but wanted to try again. Today she came in
and was all smiles. After four meetings,
she had lost 17 pounds. She keeps a food diary, is more conscious
of what she eats, exercises more
frequently, and states she feels
better all around with more stamina. She even looks like
she’s taking better care of herself. And with the help
of a statin and diet, her cholesterol is
within normal range. She wants to continue
to lose weight and get off
the statin drug. The moral of this story
is if at first you don’t succeed,
try, try again. Next slide. And a final success story
came from a patient whose A1C went from 9.5 to 6.4. She lost 13 pounds, and her COPD
is improving. The educator stated that
in the first interaction, the patient felt
as if she knew everything about her
disease process, and had no time to learn. The patient
reluctantly tried a few suggestions
from the educator, and began seeing
big results. My team has learned that
the toughest challenges are also
the sweetest victories. Next slide. One problem
that has seemed to be common
among each nurse is keeping the patients for an extended
length of time. We often have patients
who enroll in CCM, and utilize the services
for one to two months, and then we are
unable to reach them. Often their phones
are shut off, or they have had
to move quickly, and we must
discharge them until they return
to the provider, and their information
is updated. Another issue is that
as an FQHC, we bill CPT 99490. We are not authorized
at this time to bill the other chronic
care management code, and many of our patients
are complex and require as much as an hour
each month. This hinders
the nurse’s ability to enroll a new patient. The financial burden on our population
is prevalent, and each educator runs the patient’s
eligibility prior to admitting them
to make them aware of any copay or costs. This also sets
the number of admissions each educator
has each month. Next slide. For our growing
Hispanic population, we have a Spanish
diabetes education book, as well as brochures for each o the other
chronic diseases on which we focus. We use optimal phone
interpreter hotlines for translation
for our patients who do not speak English, as well as the website for the hearing impaired. We have two R.N.s
that are currently taking Spanish classes to be able to
better communicate. ADA also offers handouts
for diabetes in Spanish that we’ve found
to be very useful. We have Spanish-speaking
employees in a growing number of our locations, which seems to be the
best way to communicate. It seems that the patient
is instantly more at ease to know that
they can speak to someone face-to-face
who understands exactly what they are
trying to say. Next slide, please. As you can see, we are
still learning every day. We learn through
our successes, and we learn through
our hardships. But we know
that each individual that we treat has their
own set of circumstances, with their own successes
and hardships in life. As long as
our focus remains on making each day
better for that patient, we will succeed. Thank you.>>Monique LaRocque:
Thank you very much. Next, we’ll hear
from Allison Castleman.>>Allison Castleman:
Thank you. Hey, everybody. I just want to take
a few minutes to talk about our version
of care navigation that we’ve implemented in
Henry County, Tennessee, as part of our HRSA Delta Rule Network
grant program. It’s based out
of a hospital utilizing
a care navigator, who’s a registered nurse with a background
in case management. Next slide, please. Upon admission
to the hospital, all patients are screened using a variety
of different data sets. Information
on such things as comorbid conditions, past history
of readmissions, income, insurance, and different things
are pulled from either
their demographics, the EMR history
and the nurse’s admission assessment. This screening generates
a report for the care navigator, which you can see
in the middle of the screen there, that gives a patient
a risk score for readmission
back into the hospital. And then, there’s another
score for identified skilled nursing
facility need. If the patient
scores high, the care navigator
meets with the patient and caregiver
if possible, to create a plan of care, and for automated phone calls
to begin at discharge, if the patient
is going home. if the patient’s going to
go to a skilled facility, the care navigator
will still follow that patient for at least
30 days after discharge. If they get discharged
from the skilled nursing facility before the end
of that period, the care navigator
picks them back up to be include in our care
navigation process. Next slide, please.
So this is — we typically follow
patients at discharge for about 30 days
afterwards. After the patient’s
discharged, they begin to receive
automated phone calls that are tailored to them and based
on their condition. Most patients
typically receive calls three times a week, but again,
it is very tailored, so patients may
have two times, it may be daily, just depends on that
patient and their needs. They’ll be asked
to use their phone to enter their response
to the questions. The questions are
typically yes or no, and very — good health literacy
on those for the patient so they can
understand easily. And some others do include
specific instructions, such as asking them
to enter their weight if it’s a CHS patient. If the patient enters
a response that warrants a follow-up
by the care navigator, it shows a red flag in our care
navigation program. Next slide.
So, here’s an example of the patient
call dashboard that our care navigator would see within
the system. You can see where
the patient was called, which questions
were asked, and if the response
was within normal limits. The green boxes indicate
an all good response, and the red boxes
indicate a need to follow up. So, you can see this one, like, here the patient
was asked if they had a fever. The box indicates
it’s green, so the patient
must have indicated that they did
not have a fever. However, plenty of rest was flagged
as a response, that the patient did
not get plenty of rest, which warranted
a follow-up by the care navigator to make sure the patient
was doing okay. Next slide. Here you can see where
the care navigator contacted the patient
to see what was going on, based on those
flagged responses. And she just entered
some notes here, so that you can see
her responses, so that we can
track kind of what’s going on
with that patient. Many of these — the patient was receiving
home health services, and so we can
make sure the home health was coming, that they were
seeing the patient, that they were
addressing that, so that the patient
had what they needed, so they didn’t end up
back in the hospital, and they were getting
the services that they needed. Next slide. Other services
that our care navigator provides includes transportation
assistance, if they’re having trouble
getting to or from their physician
appointments, scheduling or
rescheduling of appointments, referrals to other
community programs, and especially
communication to and between hospitals,
providers, specialists, and other
community agencies as needed by
that patient. Next slide. So, our program
has been in place for about a year now. We started with
the orthopedic patients, we’ve been gradually
working in those core measure patients just depending on some
readmissions and need. So, we’re starting to
really see some outcomes for our program. And we’ve seen
a significant decrease in orthopedic
readmission, due in part to the
increased accountability placed on those patients through the
self-reporting system. We’ve also seen
an increased adherence to follow-up
appointments, and an increase
in communication and accountability
with community providers and physician offices. This program really helps
keep everyone working towards the same goal
with a patient, and no one wants to be
that one provider that drops the ball. So, we have, you know,
making sure that the home help comes when they say
they’re going to come, and that the patient
is really getting what they need. Next slide, please. And while all this
sounds great, of course, there’s always going
to be barriers for anything
with these programs. And so, since most
of this is phone-based, we do have
some difficulties like with hearing
-impaired patients that might have
difficulty understanding
the phone calls. Some patients may choose
not to answer, they don’t want
to be honest, because they know
if they put in that they’ve gained
five pounds, they know somebody’s
going to call them and follow up
and want to know what they’re doing
for that, are they taking
their medications, that kind of stuff. And we do occasionally have patients ask to be
removed from the program, just because of the
frequency of the phone calls. And it makes them
reluctant to join other assistance programs
that we may offer that could be
beneficial to them. So, we are still
working through those, through some of
those barriers, but all in all it has
been a rewarding program, with some pretty good
outcomes so far. Thank you very much.>>Monique LaRocque:
Thank you very much. We’ve heard from a couple
of local perspectives on how CCM
can be implemented. They’re meant
to share approaches, and not be prescriptive. This can be implemented in a variety
of different ways, if you follow
the CMS guidelines. It’s also showing how CCM
is helping communities, as well as the HCPs
and patients in those communities. Now, we’re going
to turn to talking about the
regional perspective. Beth Chalick-Kaplan
will be sharing this. Beth, can you please
start presenting, if you’re available?>>Beth Chalick-Kaplan:
Can you hear me now?>>Monique LaRocque:
Yes, we can. Thank you so much.>>Beth Chalick-Kaplan: All
right, I’m so sorry about that. I don’t quite know
what happened. But I’m so excited
to offer some CMS regional support to all of you
joining us today. I’ve enjoyed
the opportunity to work with
the Philadelphia and the northeastern
chapters of NAHN on a few local
outreach events, highlighting several
CMS initiatives. It’s been really
rewarding to hear feedback
from our local partners, especially my nurse and nurse
practitioner colleagues, regarding their work in
chronic care management. You can see from a nurse
care manager from Portland Adventist
that this work has not only been helpful
to their patients, but it’s also been
personally rewarding to the care manager. And in the second example
you see on the slide, this work
has been beneficial from a financial
perspective to a practice, and allowed them,
in New Jersey, to dedicate more staff to do
this important work. I’m personally excited
about this, because it offers
an opportunity for many
different members of the healthcare team
in a practice to directly
impact patients and improve care. Next slide, please. Next slide. Here at CMS, we know
that it’s not always easy to start a new program, and you may still have
some questions or need support. CMS national headquarters is based
in Baltimore, Maryland. However, we have
10 regions, shown above, with an office in each that serves as boots
on the ground, so to speak, to support
the implementation of all CMS programs. Next slide.
Each region has a chronic care management
and Connected Care initiative point
of contact, if you need some
guidance or assistance in spreading the word about the Connected Care
initiative. In some cases,
these contacts may be able to help you
in planning regional outreach and
awareness events locally. Each region’s office
is listed above, with the states included
in each region, and the point
of contact name, email address, for Connected Care. Please feel free
to reach out to them at that email address if you have
any questions, or are in need
of additional support.>>Monique LaRocque:
Thank you, Beth. And now, we’re going
to open it up to questions and answers. The first question
is about whether the presentation
will be made available, and the answer
to that is yes. We will have this
presentation available on the CMS OMH website, and it will be
available for download. We’ll also send an email
after that is available, so that we can tell you
and prompt you to go to the website
to download it. The next question
is for Allison. Were you billing
your services as CCM? How did the patients
react to copays? And how did you establish the care plan
in the hospital? >>Allison Castleman:
We currently do not bill for this program, but we do have hopes of,
in the future, incorporating this with
our local providers and physician-owned
practices, to establish this with the chronic
care management. I do know that
copays is something that we’ve kind of — we’re not worried about, but, you know,
definitely considered, because most of
the patients we deal with in these rural areas, that’s a big deal
for them. There was another part
of that question. Oh, the care plan. Most of it
is disease-based, and again, it goes
with that risk factor. Whenever you see in there
that talks about why they’re high-risk
for readmission, if it’s income-based, if they’ve been
readmitted to the hospital
the last several times, and then that specific
patient’s just adherence to their
medical condition, and their medications. And then, it’s also
altered as the patient — as we interact
with them, you know. We might start it
for two days a week, and when that patient’s
having a lot of difficulty,
we might increase it. So, it really
just depends on a lot of different
patient factors.>>Monique LaRocque:
Thank you very much. The next question
is for Michelle. Where can I access
the materials for the Connected
Care campaign? >>Michelle Oswald:
Hi, Monique, thanks for that question. The materials for the
Connected Care campaign are on our website, at You can also get a link
on that website to our product
ordering warehouse, to be able to order
products straight from CMS as well. Thank you.>>Monique LaRocque:
Thank you. Lauren, the next question
is for you. How were you able
to evaluate and assess
patient satisfaction, and how did you
collect their feedback in those quotes on how the program
was helping them? >>Lauren Fields:
We provide a pre- and post-survey
to all patients, and then we assess
them quarterly. So, every three months, they receive
a survey in the mail.>>Monique LaRocque:
Thank you. The next question
is for Michelle. Do automated calls count towards the required time
spent on CCM? >>Michelle Oswald:
Thanks, Monique. That’s a great question. So, automated calls,
monthly calls, can count towards that
time to bill for CCM. Again, if you’re doing chronic care
management services that are 20 minutes
or more per month, if you have someone
from your care team that’s making monthly
phone call check-ins to that patient,
yes, that can count towards the threshold
of the time.>>Monique LaRocque:
Thank you. Another question
regarding time spent. Does time spent calling
vendors and specialists to coordinate
care contribute to the 20-minute minimum
time spent in order
to bill for CCM? >>Michelle Oswald:
I’m sorry, Monique, time spent toward vendors
and what else?>>Monique LaRocque:
Specialists.>>Michelle Oswald:
Specialists, yes, yes. And, again,
so if you look at the frequently
asked questions and the facts sheets
that are on the CMS care management page, you’ll see more
specific information on some of
the ways that — information
that can help you to see
what can be counted towards that time. I do want to point out
that the 20 minutes is assumed
that there are 15 minutes of billing
practitioner time, so keep that in mind. So, anything above
that can be activities that are part
of other folks on the care team,
if you will.>>Monique LaRocque:
Thank you. The next question
is for Allison. How were you able
to coordinate between hospitals
and specialists? What do you do to find
that information, and to log that? >>Allison Castleman:
Most of our patients, of course, have — just like any patient
discharged from the hospital, it’s going to have those
appointments scheduled and identified before they ever
leave the hospital. So, a lot of our role
is just to make sure that because we do
have that information, since we’re within
the hospital system, to make sure
that they are going. That the discharge
information got sent to them, if they missed
their appointment for some reason, or if their regular
provider refers them. And we just make sure
that we’re doing a lot of follow-up
to make sure that they do attend
those appointments, and that those providers
do have the information that they need.>>Monique LaRocque:
Thank you. The next question
is for Michelle. How can an organization become a partner
in this campaign? >>Michelle Oswald:
Thanks, Monique. If an organization
is interested in becoming a partner, I would say
the first step would be to go
to the website,, and download
the partner toolkit. That will give you some
really good helpful ways to be able to support
the campaign, and have some really
good information to use. And then, give us a shout
at [email protected], and let us know
you’re interested, and we will get back to
you as soon as we can.>>Monique LaRocque:
The next question is asking us
about resources to help
healthcare professionals and health systems
implement CCM. We can direct you to the Connected Care
resource hub. There is an HCP
toolkit there, available
for you to download and share amongst
your colleagues. It also has a list of all
of the requirements on that site, so that you can see
what is permissible, as well as the FAQs. So, the next question
can be answered by any of our folks
in the field. Do you experience issues
with loss to follow-up? What strategies have you
found to be successful to overcome
those barriers? So, let’s say —
I’ll call on Allison for that one.>>Allison Castleman:
Okay, can you just — loss of follow-up,
as in patients not following up
to their appointments?>>Monique LaRocque:
That’s correct.>>Allison Castleman:
Okay. Of course,
that’s an issue, as anywhere, and I’m sure patients
have experienced that, especially in
rural areas. We really try to
work with them to make sure
if they’re not going, why are you not
going to get that? Is it because you don’t
want to pay the copay at the provider’s office, you don’t have
transportation assistance, you don’t like
that provider? And so, we really try to
get to the nitty-gritty, and if, you know,
we can either provide them
financial assistance for transportation
or we can say, Hey, let us set it up
for you, to help get those
patients and then again, following back up to make
sure Did you finally go? Hey, let us
schedule it again, and let us —
we’re really going to, you know,
whatever you need, to really try to break
down those barriers as to why
they’re not going, so that we can help them
make sure that they do go.>>Monique LaRocque:
Thank you. The next question is
for Beth and/or Michelle. How can an organization
in one of the states get materials in relation to the campaign that
they can use to support their community
education efforts? >>Michelle Oswald:
So, Beth, I was waiting, I wasn’t sure if you were
going to answer first. I think they can
get materials a couple of ways. So, if you’re in one
of the regions, Beth shared a slide
that will be available to you in the future
on our website, that has a list
of the regional contacts for chronic
care management, so feel free to reach out to any one
of those folks. And then,
as I’ve mentioned, if you want to order
products directly, you can go
to the website, and there’s a link to the CMS
product-ordering website to get materials
there as well. Beth, did you
want to chime in?>>Beth Chalick-Kaplan:
No, I was actually hoping that you would say
exactly that, thank you.>>Michelle Oswald:
Great, so we’re
on the same page. I will also mention
Beth and others in the regions
are planning to be at
the regional activities, maybe some health fairs or some conferences
coming up, so be on the lookout
there as well, they’ll have materials
there, too.>>Female Speaker:
Thank you. And just a quick overview again on some
of those materials, there are materials
that can help you educate your patients while they’re in
the waiting room, as well as in office. So, there are postcards, and there
are also posters that you can hang
in your waiting room. And then in terms
of educating some of the staff on CCM, there’s the HCP toolkit
as well. And there’ll be
more activities and materials available
online on the website.>>Monique LaRocque:
The next question is for Michelle. Can you please explain
the 15 minutes of billing practitioner
time in relation to the 20 minutes
for monthly billing? >>Michelle Oswald: Sure,
let me clarify that. And so, the 15 minutes of
billing practitioner time is that initial
20 minutes. So, there are
certain clinicians that are able to be
billing practitioners, so that’s the doctor,
the R.N., the nurse practitioner,
and others, and those are outlined
in the FAQs sheets. So, those activities that
that billing practitioner is doing need
to be the foundation, that 15 minutes. And then any time after that that’s done
by the clinical staff, such as reviewing
medical records or doing, you know, other
coordination activities, is in addition to that
15 minutes. So, hopefully
that helps clarify.>>Monique LaRocque:
Thank you, Michelle. The next question
is for Lauren. Do you have any lessons
learned or practices that you are using
to capture time spent on each patient, when there are non-CCM employees providing care
for billable services? >>Lauren Fields:
We do not, at this time, have anything
for the ones that are not CCM nurses. The nurses do go into
the clinics once a week, and they speak
with each provider about the patient. So, that time, of course,
is counted, but not counted toward
the billing purposes, just counting it
in the sense of what the nurse
is doing in the field. But as far as the time
that the provider’s been, you know, all that we have is what
they do in the clinic, and what they do
with each nurse. I hope that helps, I hope
that’s not confusing.>>Monique LaRocque:
Thank you.>>Beth Chalick-Kaplan:
This is Beth, and I might be able
to help here, too. I can tell you that
some of our partners have actually incorporated
this program, similar to the way
lawyers bill for services, and they use a stopwatch
to start and stop when they’re
providing care that falls
under this program.>>Monique LaRocque:
Thank you, Beth.>>Michelle Oswald:
Monique, this is Michelle, may I go back
to the question about the 15 minutes for
the billing practitioner, and just to
clarify further? So that’s
for billing code, CPT code 99490,
for regular non-complex. That’s what assumes
15 minutes of work by the billing
practitioner. So, the additional
more complex code and the add-on code
are for additional time. Hopefully, again, that
further clarifies that.>>Monique LaRocque:
Thank you. And Michelle,
one other clarification. Does a patient have to
be spoken to every month? What about the times when
you leave a voicemail, can that count? >>Michelle Oswald: So, that’s
a great question, Monique. And I will say, so first
of all, no, patients do not have to —
first of all, you don’t have to speak
to patients every month, you don’t have
to make contact with patients
every month. Monthly is the maximum that you can
contact patients. We have received
that question at CMS, and it’s sort of
a gray area. I mean, you certainly,
if you were making repeated calls
to a patient, and you don’t reach them, you certainly want
to be paid for that time that you made
towards them, towards the effort
of getting in contact with them. But if you — again,
it’s a gray area, I’m not —
you know. I guess use
your best judgment. If you’re making
a phone call, and it’s 30 seconds and you haven’t
reached that patient, I’m sure there
are other times that you have toward that patient you
may be able to count. So, I’ll just
leave it there, that I think
it’s going to be a case-by-case basis.>>Monique LaRocque:
Thank you. I’m going
to open the floor to either Lauren,
Allison, or Beth to answer
and to contribute to this response. Do you have
any best practices for enrolling
patients in CCM, and how do you market
it to them? >>Lauren Fields: I can
tell you what we do is, that we go by
a patient roster, or the patients
that have two or more of the diagnoses
that we focus on. And we send those
patients mailers, and ask them
to contact us if they have
any interest. And that’s the best way
that we’ve found to enroll patients. We also have flyers up
in all of our clinics that allow the patient
to contact us.>>Allison Castleman:
This is Allison, I was just going to chime
in on that real quick. Now, while we currently
don’t bill for CCM, the way we enroll people
in our navigation program, again you all saw
that risk factor that’s sent over
to the care navigator. If the patient falls
within that risk category for readmission, our care navigator actually goes up
to the floor, presents them with some information
about the program, tells them a little bit
about how it works, what the structure
of it is, works on that care plan
if they agree. And it kind of, you know, follows back up
with the discharges to make sure that
everything is okay there. So, we get them
kind of while they’re a captive
audience here, and that works out
pretty well for us.>>Beth Chalick-Kaplan:
This is Beth. I can share
that one practice that we’ve worked
with, shared, that they also had
some patients concerned about the copayment
or not understanding that responsibility. And CMS is unable to
address that issue, because it was written into legislation
that way, but what that practice
did was took time to describe what care management
services really are, and how important
they are, and how time-consuming
they are. And they found that when
they did with patients, they got better buy-in
and agreement, and it seemed to lessen
the concern or objection regarding co-insurance
for some patients.>>Monique LaRocque:
Thank you very much. So, the next questions
relates to enrolling patients, and similar to how do
we identify those. What is the best
to identify CCM patients if you’re just starting
to implement the program? Are providers
doing any referrals to care managers? >>Michelle Oswald:
So, this is Michelle, I’m wondering if maybe
Lauren or Allison can talk to how they’ve been able
to identify patients, particularly Lauren,
in your practice?>>Lauren Fields:
Our providers do refer CCM patients to us. Also, they send
medical messages, flags or emails to the CCM nurse
in their clinic. And they seem to have
a good relationship with them,
and that works out well. So, right now,
that’s how we do it, just the medical
messages mostly, and through the flags
that they send referrals to enroll those patients.>>Beth Chalick-Kaplan:
This is Beth. Lots of patients
have been identified through electronic
health records, in primary care office settings
by office managers, running a report
of diagnosis codes and comparing
that to eligibility for CCM services, and targeting
patients that way. Either when they come in for their next
appointment, or an outreach call is
made to discuss services and then bring
the patient in to start development of a care plan. Hope that helps.>>Monique LaRocque:
Thank you. There is a question
about implementing CCM and tools to help. The question is, Do we have any
sample care plans? We would like to direct
you to the HCP toolkit. It does have an outline
of the elements that may be considered
for a care plan. The next question
is for Michelle. It relates to who can be considered
clinical staff. For example,
can a medical assistant or a LVN help to support care
management?>>Michelle Oswald:
Sure, thanks, Monique, for that question. So, in the FAQs that are
on the care management, there is — actually
question number one — that it asks
who qualifies as clinical staff. So, it really
varies state to state. It depends on state
law licensure, and scope of practice, so that’s not really
a particular question that I can
specifically answer. So, I will just say
that it does vary from state to state, as to who can be
considered clinical staff to be able to
count your time towards chronic
care management under the billing
practitioner. And maybe others
on the call can clarify
that a little bit more, maybe from where
they’re coming from.>>Monique LaRocque:
Thank you, Michelle. The other question
is related to whether a patient
who has diabetes and is on dialysis able to be considered
eligible for CCM. Michelle, if you can
take this question.>>Michelle Oswald:
Sure, I’ll start, and again, others,
feel free to chime in. Again, so under chronic
care management, it’s for patients, Medicare beneficiaries
with two or more chronic
conditions. You know, given
those conditions, I’m sure there are
other comorbidities, so more than likely
this patient probably does have two
chronic conditions, that would be able
to be supported if this person’s
a Medicare patient.>>Monique LaRocque:
Thank you. This next question
is for you, Michelle, as well. When the patients
are dually eligible, how does the billing
of Medicaid work for the copays
and deductibles? >>Michelle Oswald: So,
that’s a great question. And so, again,
that’s going to vary from state to state, depending on the state
Medicaid program. As a CMS perspective,
you know, the hope is if someone
is dually eligible, if they’re Medicare and
have Medicaid as well, the copayment
and coinsurance should be covered. And I say should,
given that we have heard instances
and been getting feedback
that there are patients that are getting bills. If that’s the case, we’d
like to hear about it, so that we can figure out what’s going on
in that particular state. So, does that answer
the question, Monique? I know there are others
that want to chime in on that.>>Monique LaRocque:
Yes, it does, thank you. Well, we have reached
the conclusion of our webinar,
What Nurses Should Know About Chronic
Care Management. We invite you to visit us on our chronic
care resource hub, at We are interested
in staying connected with you as well
as looking for partners who are interested
in implementing CCM and educating others about Connected Care
in their communities. Please do stay
on the webinar for a few questions. We’d love to hear
your feedback, as well as if
there’s anything that you’d like
to reach us for, or have any questions, please email us
at [email protected] Thank you so much
for your time.

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