November 2014 Newsletter

Improving Primary Care: A Guide To Better Care Through Teamwork    


Practice redesign just got a little easier thanks to a new website from the MacColl Institute for Health Care Innovation at GroupHealth. The resource-rich -provides a wide range of materials and lessons learned from 31 exemplary primary care practices across the country that have markedly improved care, efficiency, and job satisfaction by transforming to a team-based approach.


Practical advice, case studies, and tools posted on the website explain how expanding the roles of team members through increased training and standing orders can develop trust, teamwork, and efficiencies in a practice. The website profiles key team members that commonly are used to improve care in primary care practices: MA, RN, LP, CP, BHS. For example, in addition to rooming patients, running simple lab tests, and staffing the front desk, medical assistants can perform pre-visit planning to identify gaps in evidence-based care, call patients who are overdue for services, and provide health coaching support.


The website also describes how the exemplary practices went about improving an array of processes and functions, including Improving Care Through Teamwork, Enhancing Access, Self-Management Support, Population Management, Care Management, Medication Management, Referral Management, Behavioral Health Integration, Communication Management, and Clinic-Community Connections


In short, the website explores how to build the team and do the work.


Several Pennsylvania practices are among the 31 exemplary practices showcased: Eleventh Street Family Health Services Center in Philadelphia, North Willow Grove Family Medicine in Bucks County, and The Wright Center for Primary Care Mid Valley near Scranton.

Medicare to Begin Paying for Chronic Care Management


Starting in January, Medicare will begin to pay for non-face-to-face time spent managing the chronic care needs of Medicare patients. Expected reimbursement is a little over $40 per qualified beneficiary per calendar month.


For providers to bill for the services, the Medicare patient must be diagnosed with two or more chronic conditions and must provide written consent that they have been told what chronic care management (CCM) services are and how to access them, that only one provider at a time can be responsible for coordinating their care, that their personal health information will be shared with other providers in the course of coordinating their care, that they can refuse CCM services and revoke their consent at the end of any calendar month, and that they will be responsible for any copayments or deductibles.


Monthly billing requires care teams to provide at least 20 minutes of CCM services in that month. CCM services are described as reconciling and monitoring the patient's medications, ensuring receipt of all recommended preventive services, monitoring the patient's physical, social, and mental condition, providing education to the patient and/or family, identifying and arranging for needed community services, and communicating with home health agencies or other used community services. CCM services are to be provided by licensed or certified professionals or staff.


Providers, in effect, will attest when they bill for CCM services that they are (1) using "CCM certified technology" (i.e., a certified electronic medical record) that enables them to (2) maintain an electronic care plan, that they (3) provide 24/7 patient access to a member of the care team, (4) provide services during transitions of care, and have the ability to (5) coordinate with home- and community-based services.


Although Medicare has not listed specific documentation requirements, a white paper about billing for CCM services suggests the types of documentation providers should keep.

Resource: Patient-Centered Medical Home and Health Home Webinar

Maine Quality Counts recently posted a webinar that focuses on high risk patients, specifically those at risk of substance abuse. The webinar focuses on the SBIRT approach (Screening, Brief Intervention, and Referral to Treatment) for these high risk patients. More training resources for SBIRT training can be found here.

Best Practices Spotlight

Dr. Alexander Spasic, MD Family Practice 

in Carlisle is closing gaps in care with a unique reminder system. Each day, the front desk staff reviews the next-day patient list to identify needed labs and screenings. They then mark reminders on each patient's superbill using letter stickers leftover from their old paper charts. For example, M is used to notify that the patient is due for a mammogram. While an EMR-based reminder system can be highly efficient, many practices opt to use a paper reminder system, at least for a while, when testing how to alert providers to due/overdue services.

In The Literature


Study Shows Rapid Expansion of PCMH Initiatives with Payer Incentives


shows both providers and payers stepped up their involvement in Patient Centered Medical Home (PCMH) initiatives between 2009-2013. In that time period, 88 more PCMH initiatives were introduced in the US that featured payment reform, covering approximately 21 million patients. Although fee-for-service has remained the most prevalent payment model, per-member per-month payments and pay-for-performance bonuses have become more common.
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