Patient-Centered Chronic Care Plan

In January 2015, the Centers for Medicare and Medicaid (CMS) announced a new initiative: Chronic Care Management (CCM). CCM is intended to assist clinicians in the routine care of patients with two or more chronic conditions by providing a reimbursement of about $40 per month, for non-patient-facing activities that providers deliver to their patients. The intent is to recognize the effort clinicians put into caring for the chronic care patient population as they deliver services such as prescription refills, prior authorizations, and getting copies of imaging or lab results from other providers. For a minimum of twenty minutes spent on non-patient-facing tasks per month, clinicians may submit a claim under CCM. However, CMS has included a number of requirements for CCM Scope of Service which must be met before any claims are submitted.

One important element of the Scope of Service is a comprehensive, patient-centered Care Plan. The Care Plan must be based on the environmental, psychological, functional, and physical needs of the patient and it must reflect the patient’s values. It provides an important tool for the patient’s care team and any outside provider called upon when the care team is not available. Several elements which are required by CCM may already be already be present in the patient’s electronic chart: problem list, medications, and allergies. But most components of the Care Plan are missing from many EMRs. If you are preparing to bill for CCM, you must account for these components on your own.

The missing components of the Care plan may be grouped into 2 main categories:

  • Symptom management
  • Care management
  1. Symptom Management

CMS requires a structured recording of all medications and allergies for each CCM patient. But just having a list of medications and a list of allergies is not enough. The Care Plan must also include:

  • Medication reconciliation
  • Potential interactions
  • Review of patient compliance with drug regimen
  • Oversight of patient self-management of medications

Each of these elements must be documented. Reconciliation of medications ensures that the patient is only taking those drugs which are currently indicated for each condition, while compliance review gives the clinician a chance to explain to the patient why each medication is needed and how it should be taken. Documenting potential interactions makes it clear to both patient and clinician what precautions, if any, need be taken. Oversight also gives clinicians a chance to review all drugs the patient is currently taking including OTC substances, and document all of them.

But it doesn’t end there. Management of symptoms must specifically be addressed in the Care Plan, including:

  • Measureable treatment goals
  • Expected outcome and prognosis
  • Preventative care

Clinicians are responsible for explaining and documenting treatment goals. They must also document their expected outcomes for the patient with respect to each chronic condition, and while they must meet with the patient at least once a year to revise and update the plan, they must also ensure that the patient is receiving appropriate preventative care during the year.

  1. Care Management

A patient’s chart may contain information about caregivers and social services, but frequently this data is buried in an encounter area and is not easily observable. The Care Plan requires clear documentation for:

  • Planned interventions and who is going to intervene
  • Community and social services ordered and access to those services
  • Description of how agency services and specialists outside the practice will be coordinated
  • 24/7 access to plan by care team and outside providers

Interventions may be as simple as caregivers reminding the patient to take daily medications, or may include home phlebotomy visits by a qualified technician. The clinician must document each intervention so that patient and caregiver are clear regarding the assignment and scheduling of these responsibilities. Social services may consist of adult day care, local senior transport, or other services. Clinicians must be aware of and document each of these services and describe how the patient will gain access to each. Coordination of services must also be made clear.

The Care Plan also requires inclusion of specialists’ contact information and an accounting of how all of the patient’s specialists will be coordinated. This information must be maintained in the patient’s EMR.

Because the Care Plan contains protected health information, HIPAA standards apply. A paper copy or electronic access (for example, via secure patient portal) must be given to the patient. For the care team, access to the Care Plan must be electronic, 24/7, and must be available on the same basis to clinicians outside of the practice who are directly involved with the patient’s care.

It’s important to note that the Care Plan cannot be sent to providers via fax, but it may be stored and sent via secure electronic transmission. Documentation that a copy of the plan has been given to the patient must be kept in the EMR.

Dulcian Health has formulated a Care Plan which meets all CCM requirements. We make it easy to complete and maintain all necessary information in your EMR. Don’t go it alone! Contact Dulcian and let us help you be compliant with your CCM efforts.

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Posted in BLOG, chronic care management, Healthcare

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