quality improvement workshop - caravan health
TRANSCRIPT
Summer 2019
Agenda
News Update .........................................................................................9:00 – 9:30 a.m.
Leading System Change ..................................................................... 9:30 – 10:00 a.m.
Break .................................................................................................... 10:05—10:15 a.m.
Foundations of Chronic Care Management & Patients in Transition ................................................................... 10:15 –12:15 p.m.
Lunch ..................................................................................................... 12:15—1:00 p.m.
Data to Drive Transformation: Compass ............................................... 1:00—2:00 p.m.
Break ..................................................................................................... 2:00—2:15 p.m.
Reactive vs. Proactive Care: Hierarchical Condition Category .............. 2:15 –3:15 p.m.
Wrap-up ................................................................................................. 3:15—3:30 p.m.
Quality Improvement
Workshop
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Leading System Change
What is Team-Based Care
____________________________________________________________________________________________
____________________________________________________________________________________________
Barriers to Team-Based Care
• Change becomes harder when a person is stressed, tired, or ____________
• Each group is __________________ separately with different norms and self perceptions.
• Habits, experience, and ___________ create norms of behavior that are difficult to challenge.
Benefits of Team-Based Care
• Better outcomes, financial results, and __________________________________________________________
• Reductions in ______________________________________________________________________________
• Better patient satisfaction
Attributes of Team Based Care
• Shared ____________________________________
• Leadership
• Continuity and regular meetings
• __________________________________________
• Shared physical space
• Psychological safety
• Task ______________________________________
• Effective help among team members
• Team coordination
• Constructive conflict resolution
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Overcoming Barriers
• Negative emotions ________________________________
• Use emotion for good:
• Share a _______________________________________________
• Other: ________________________________________________
• Shrink the change—one piece at a time
• Create ___________________________________
The rider cannot command the elephant.
• ______________________________________
• ______________ obstacles
• Follow bright spots, “See, others can do it.”
Action Planning Worksheet
What is the area of resistance? (be specific) _______________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
What story will land? How can you tell a story that will demonstrate an emotional reason to change? ___________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
What is the first small change you will make? _______________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
How will you celebrate your success? What other small changes can you make? __________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
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Foundations of Chronic Care Management
& Patients in Transition
Why Care Coordination?
Duplicate tests are ordered ___ ____% of the
time when seeing 4 or more specialists
______________ % of adults report that
their PCP was not informed of their ED visit
_________% of the time, PCPs treated with-
out seeing the hospital D/C summary
_______________% of patients left the office
without understanding what they were told
Care Coordination: The Solution
2019 Caravan CCM Goals
____________ % Average Caravan CCM Participation
____________ % 2019 Goal Caravan CCM Participation
If we are impacting ______ out of 1000 patients, we only need to
reach ________ more patients to meet the 2019 Caravan goal.
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Comprehensive Transition Processes
Allows you to ______________ through-out
healthcare settings
_______________ experiences navigating
the healthcare maze
Improved quality and _________________
______________ to resources for the social
determinants of health
Improved ______________________ of
resources
Significant opportunities to prevent patient
harm and improve population health
Best Practice for a Successful CCM Program
• ______________________ is better than telephonic support
• Have _________________ for targeting beneficiaries
• Consider training & experience of care managers
• Timeliness and comprehensiveness of interventions for patients undergoing care transitions
( _______________________________________________________________________________________ )
• Emphasis on _______________________ Medication Management
• _____________________ MUST be involved in working with the Care Management Team
Patient Consent and Documentation
Must include:
• _______________________ can provide _________________ during the calendar month.
• Can be verbal or written.
• Document in the patient record that this information was provided and whether accepted or declined.
CCM Program Requirements
• ______________________ (verbal or written)
• Comprehensive, patient centered _______________________________________________
• Manage ___________________________________________________________________
• __________________________ home and community-based providers
• _____________________________________________ with a designated care team member
• _________ access to practitioners
• Certified ___________________________________________________________________
• Ability to communicate ______________________ with patient and other providers
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Care Plan: Nursing Interventions
• ________________________ Self-management of conditions and self-care regimens.
• ________________________ Symptoms and adherence to treatment plan
• Engage: Elicit and leverage ________________________________________________________________
• Communicate: Feedback to ________________________________________________________________
General Supervision, Auxiliary Personnel
• Provider ______________________________ have to be in the facility.
• Provider does take ________________________________________________________________________
• Auxiliary personnel include: RN, MA, __________________________________________________________
Comprehensive Care Plan
Provider Documentation
• ___________________________________
• Problem list
• ___________________________________
• Measurable treatment goals
• Expected outcome ____________________
Nurse Assessment & Documentation
• Nursing assessment
• Timely _________________________ care
• Adherence to _____________________________
• Oversight of patient self-management
• _________________________________________
and plan to overcome barriers to meet goal
Provider Billing Option
• New Code ______________________________
• ___________________________________ Provider CCM time paid at ______________________________
• Cannot bill with ___________________________________________________________________________
Notes
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Establishing Nursing Roles in CCM
Nurse
• Initial assessment
• ___________________________ identified goals
• _____________________ to achieving goals
• Develop _________________________________
• _________________________ frequency/method
• Delegate ________________________________
LPN/ MA
• Manage ________________________________
• Document consent
• _____________________________ appointments
• Perform follow up calls and record progress
• _____________________ concerns to RN
• Work within ____________________________
Cost Sharing for Patients
• Patients are responsible for the usual Medicare Part B cost sharing
• Majority of dual eligible beneficiaries ( __________________________________________________________ )
have supplemental insurance which covers ______________________________________________________
• ________________________ must provide wrap-around coverage of CCM
Nominal Gifts
• Valued at __________________________/ visit
• Valued at __________________________ per patient annually
• Stimulus for ________________________________________
CCM Flow
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Enrolling Patients Workflow
Identifying Patients: Paths to Build a Case Load
Chronic Disease Path Transitions Path Utilization Path
Many Activities Count Towards CCM Time
• _______________________________________________________________________________
• Review of _________________________ and test results
• Facilitating ________________________ after discharge from hospital or SNF
• Patient education for self-management
• Coordination of care and exchange of ________________________________with other providers
• Providing referrals
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CCM Action Planning Worksheet
What is the area of resistance? (be specific) _______________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
What story will land? How can you tell a story that will demonstrate why change is needed? __________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
What is the first small change you will make? _______________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
How will you celebrate your success? What other small changes can you make? __________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
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Using Patient Cohorts to Drive System Transformation
Chronic Disease Matters
Together, these two groups of conditions accounted for 56% of the spending slowdown:
• _____________________________________________________________
• _____________________________________________________________
Better Disease Management
Hospital admissions for ischemic heart disease: __________________________
Admissions for stroke: ______________________________________________
Shrink the Goal: Focusing on Riskiest Patients
Caravan uses 2 risk stratification tools to identify patients most likely to benefit from Chronic Care Management:
• _____________________________________________________________
• _____________________________________________________________
Shrink the Goal in Order to Start
Level 1: Practice Level Interventions
• ____________________________________________________________________ via better chronic care management
Level 2: System Level Interventions
• Manage or Reduce __________________________ spending
• __________________________________ palliative care and hospice
• _______________________________
• Clinical episodes cost Analysis
Common High-Risk Selection Consideration
Disease Based: Focus on high yield Dx— _____________________________________________
Event Based: Focus on high cost utilization— __________________________________________
Socioeconomics: Focus on patient barriers/limitations
Caravan High-Risk Patients
_________ Chronic Conditions + 1+ ________________________________________________
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Lightbeam Training Resources
Patient Cohorts: Relias training video,
• Course Number: LB1102
• Course Name: Lightbeam: How to Pull Patient
Cohorts
Johns Hopkins: Relias Training video,
• Course Number: LB2013
• Course Name: Lightbeam: How to Identify High Risk/
High ATI Patients using Johns Hopkins
To watch training video in Relias, search by course number and/or name. Contact Caravan Health Tech Support for
assistance.
PDF instructions are located in Caravan Health’s Portal. Search word:
• Cohort pulls up Care_Management_Patient_Cohorts
• Johns Hopkins pulls up Johns_Hopkins_High_Risk_High_ATI
Once logged in,
1. Click Document Exchange, located on the left-hand side of the screen.
2. Click Search.
1
2
3. Type Cohort (or Johns Hopkins) in the search field, when the pop-up window appears.
4. Click the Search button.
5. Open the respective document.
3
4
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Reactive vs. Proactive Care :
HCCs in Practice
HCC’s and Other Factors Create the Risk Adjustment Factor
_____________,
________ and
OREC*
+ HCC Codes = RAF
*OREC = Original Reason for Entitlement Code (old age and survivors insurance, disability insurance
benefits, end stage renal disease, or combinations)
What about the Patient?
Think of this as ________________________________________________________________________________
• Like medication reconciliation
• Are you addressing needs?
Start with the Annual Wellness Visit:
• Review ____________________________________
• Use the ____________________________________________________ to identify at risk patients
Where Do HCCs Come From?
Less Sick
(Or _______________)
More Sick
(Or _______________)
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Underpinnings of Nurse Lead AWV
__________________________________ : The MLN on AWV’s calls for “Establish[ing] a list of beneficiary risk
factors and conditions for which primary, secondary, or tertiary interventions are recommended or underway.” [MLN]
__________________________________ : “Medicare Part B covers an AWV if performed by a: Medical
professionals (including a health educator, registered dietitian, nutrition professional, or other licensed practitioner),
or a team of medical professionals directly supervised by a physician (doctor of medicine or osteopathy)”. [MLN]
__________________________________ : “Direct supervision in the office setting means the physician must be
present in the office suite and immediately available to furnish assistance and direction throughout the performance
of the procedure. It does not mean that the physician must be present in the room when the procedure is
performed.” [CFR 410.32(b)(3)(ii)]
__________________________________ :Remember CMS only looks to claims. More than 12 codes, you may need
to keep an eye on getting the codes on a different claim. A patient with 12+ conditions likely needs a lot of care and
is seen frequently.
Big Six
Focusing on 6 common chronic conditions to emphasize items that should not be missed.
HCC Name HCC #
Diabetes with Chronic Complications 18
Diabetes without Complications 19
Congestive Heart Failure 85
Specified Heart Arrhythmias 96
Vascular Disease 108
COPD 111
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Exercise Two: Patient Example
Subjective:
72 year diabetic male returns with ankle pain.
C/o increased L ankle pain swelling x3 weeks.
CHF and DMII- stable.
Requesting a refill of Lasix and Metformin.
No other complaints at this time.
PMHx:
amputation last year
Family/Social Hx:
Pt & wife are snow birds October-March each year. They have a 5th wheel in Surprise, Arizona. Since the amputation last year, it has become difficult to get into the RV.
Objective:
Weight: 297 Height 70. B/P 125/90.
HEENT: PERRLA
Resp: denies SOB & chest pain
Muscular Skeletal: Left ankle slightly swollen. Right BKA
Psych: stable, depression in remission since starting Cymbalta 06/2018. Wishes to continue current medication.
Assessment:
1. Sprained Ankle
2. Diabetes Mellitus Type 2
3. Congestive Heart Failure (Complicating Diabetes)
4. Complete Traumatic Amputation at level between knee and ankle,
5. Major Depressive Disorder, single episode, in full remission
6. Morbid Obesity due to overeating
Plan:
1. Rest L foot x 2 weeks, ice 20 min 3x/day, elevate. Return next week if symptoms worsen
2. Refill Lasix, Metformin, Cymbalta. F/u in 6 mo.
3. Standing order for lab, complete prior to next visit.
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Test Your HCC Coding: Please Circle All Applicable Diagnosis Codes
S93.401A Sprain of unspecified ligament of right ankle, initial encounter
I50.9 Heart failure, unspecified
S93.409D Sprain of unspecified ligament of unspecified ankle, subsequent encounter
I50.32 Chronic diastolic (congestive) heart failure
S93.402A Sprain of unspecified ligament of left ankle, initial encounter
I50.33 Acute on chronic diastolic (congestive) heart failure
S93.401S Sprain of unspecified ligament of right ankle, sequela
I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure
M25.471 Effusion, right ankle F33.42 Major Depressive disorder, recurrent, in full remission
M25.473 Effusion, unspecified ankle F32.0 Major Depressive disorder, single episode, mild
M25.579 Pain in unspecified ankle and joints of unspecified foot
F32.5 Major Depressive disorder, single episode, in full remission
M25.572 Pain in left ankle and joints of left foot F33.40 Major Depressive disorder, recurrent, in remission, unspecified
R22.4 Localized swelling, mass and lump, lower limb
F32.9 Major Depressive disorder, single episode, unspecified
E66.01 Morbid (severe) obesity due to excess calories
Z60.9 Problem related to social environment, unspecified
E66.1 Overweight Z60.0 Problems of adjustment to life-cycle transitions
E66.3 Drug-Induced Obesity Other obesity due to excess calories
E 10.9 Type 1 diabetes mellitus without complications
E66.09 Obesity, Unspecified E10.69 Type 1 diabetes mellitus with other specified complications
E66.9 Body mass index (BMI) 40 or greater, adult E10.9 Type 1 diabetes mellitus without complications
Z68.4 Partial traumatic amputation at level between knee and ankle, right lower leg, sequela
E10.8 Type 1 diabetes mellitus with unspecified complications
S88.121S Partial traumatic amputation at level between knee and ankle, left lower leg, sequela
E13.69 Other specified diabetes mellitus with other specified complication
S88.111S Complete traumatic amputation at level between knee and ankle, right lower leg, sequela
E11.9 Type 2 diabetes mellitus without complications
S88.912S Complete traumatic amputation of left lower leg, level unspecified, sequela
E11.8 Type 2 diabetes mellitus with unspecified complications
S78.112S Complete traumatic amputation at level between left hip and knee, sequel
E11.69 Type 2 diabetes mellitus with other specified complication
S78.111S Complete traumatic amputation at level between right hip and knee, sequela
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Test Your HCC Coding
Option 1 – Capture of Moderate Diagnostic Specificity
Option 2 — Capture of Comprehensive Diagnostic Specificity
Diagnosis Narrative ICD 10 Code HCC Code Risk Adjustment
Factor (RAF) Medicare Advantage
Annual Payment
72 year old, male
Originally non-disabled BASE PAYMENT**
0.395 $3,700.17
Sprain of unspecified ligament of left
ankle, initial encounter S93.402A None None None
Complete traumatic amputation at level
between knee and ankle, right lower
leg, sequela
S88.111S HCC 189 0.521 $4,880.47
Major Depressive disorder, recurrent,
in remission, unspecified F33.40 HCC 59 0.373 $3,494.08
Type 2 diabetes mellitus without
complications E11.9 HCC 19 0.121 $1,133.47
Heart failure, unspecified I50.9 HCC 85 0.337 $3,156.85
Total Risk Adjustment 1.747 $16,365.04
Diagnosis Narrative ICD 10 Code HCC Code Risk Adjustment
Factor (RAF) Medicare Advantage
Annual Payment
72 year old, male originally non-disabled BASE PAYMENT
0.395 $3,700.17
Sprain of unspecified ligament of left
ankle, initial encounter S93.402A None None
Complete traumatic amputation at level
between knee and ankle, right lower
leg, sequela
S88.111S HCC 189 0.521 $4,880.47
Major Depressive disorder, recurrent,
in remission, unspecified F33.40 HCC 59 0.373 $3,494.08
Type 2 diabetes mellitus with other
specified complication E11.69 HCC 18 0.374 $3,503.45
Heart failure, unspecified I50.9 HCC 85 0.337 $3,156.85
Morbid (severe) obesity due to excess
calories E66.01 HCC 22 0.365 $3,419.14
Total Risk Adjustment 2.365 $22,154.16
Capturing comprehensive specificity resulted in an expected additional payment of: $5,789.12
Workshop Materials Summer 2019 Quality Improvement Workshop Materials can be found here:
https://caravanhealth.com/qiw/materials
Spring 2019 Quality Improvement Workshop Materials can be found here:
https://caravanhealth.com/qiw/materials-archive
Additional Feedback email: [email protected]
Quality Improvement Workshop
Virtual Meeting July 9th
11:30am – 1pm Central Time
https://caravanhealth.com/spring2019-virtual/
On July 9, we’re going to reconvene all of our experts and review a shorten version of the
workshop. The session will be a great opportunity to review material or get an insight into something
that you didn’t quite get at the time. You may not have even realized you missed it until you got back to
the office. If you didn’t attend a workshop and heard about something, please join us.
Population Health Nurse
In-Person Training https://caravanhealth.com/phn/overview/