quality improvement workshop - caravan health

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

Proprietary & Confidential. Not for Distribution

Proprietary & Confidential. Not for Distribution 3

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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

4 Proprietary & Confidential. Not for Distribution

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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

https://www.encoderprofp.com/epro4payers/i10cmHandler.do?_k=201*E10.69&_a=view



https://www.encoderprofp.com/epro4payers/i10cmHandler.do?_k=201*S88.912S&_a=viewDetail

https://www.encoderprofp.com/epro4payers/i10cmHandler.do?_k=201*S78.112S&_a=viewDetail


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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


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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/

quality improvement workshop - caravan health

Documents