On Monday, June 1st at the American Society of Clinical Oncology’s Annual Meeting, ACT.md will demonstrate our ability to develop a collaborative and patient-friendly care plan and send it directly into the Epic Electronic Medical Record.

ACT.md was selected to participate in ASCO’s first Interoperability Demonstration because of our unique approach: connecting all members of the care team, facilitating safe and reliable hand-offs, providing a space for collaborative care planning, and involving the patient and their family in a way they’ve never experienced. For the first time, the patient AND their family/caregiver understand who is on their dynamic care team, what everyone’s roles and responsibilities are, and what activities associated with their care plan (medical and non-medical) need to take place and when they should take place. Their goals are reflected, and they have a way to communicate with their care team in a structured, asynchronous fashion.

Our Chief Medical Information Officer, Dr. Narath Carlile, and our Director of Sales and Marketing, Christina Strubbe, will be at the Annual Meeting, "Illumination and Innovation", to drive this demonstration. They will also be available to talk with oncology leaders about how to support team-based care models including the CMS Oncology Care Model (OCM) and Oncology Patient Centered Medical Home (OPCMH). I encourage you to reach out to engage in a discussion about emerging care models and interoperability.

What is it?

The new CPT code (99490) allows physicians to bill for 20 or more minutes that their staff spends on non-visit-based care coordination activities each month for their Medicare patients.

So what?

Quality care requires a lot of coordination work between visits, and usually this responsibility falls on the primary care provider. Since coordination is not a visit or procedure, it has not been reimbursed in the past. Many providers, of course, already coordinate their patients’ care because it is the right and necessary thing to do for positive outcomes—however, it comes at a cost to their practice. The new CPT code can help to offset some of that cost. Now, reimbursement is in-line with realistic workflow and quality.

The bottom line: “A physician caring for 200 qualifying patients could see additional revenue of roughly $100,000 annually.”

How is it done?

In order to bill for this code the following conditions must apply to the patient:

Patient requires at least 20 minutes per calendar month of clinical staff time coordinating care or communicating with the patient (under general—not direct—supervision)

Patient suffers from 2+ chronic conditions expected to last at least 12 months or until patient’s death

The chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline

Additionally, the practice must meet the following requirements:

Use a certified EHR (which includes 2011 or 2014 certifications that meet the core technology requirements)

Offer 24/7 access to clinicians (who have access to the care plan) to handle urgent care needs

Maintain a designated practitioner for each patient

Regarding the care plan:

The physician must collaborate with the patient to develop a comprehensive care plan that is accessible to the care team 24/7 — however, this does not have to be created or transmitted by the EHR, and could be fulfilled more effectively by a platform that is designed to create and share a care plan amongst the whole team caring for a patient

The electronic care plan should facilitate caring for the patient during transitions

Notably, it must be possible to share this care plan digitally with the patient and external providers (including community providers) and the patient needs to have web based access to this as well

Care management includes assessment of the patient’s medical, functional and psychosocial needs.

And the patient will need to do the following:

Consent (annually) to you providing CCM services

Pay the copay for each month you bill for CCM services, approximately $8. (Of note, many patients will have secondary insurance which will cover this.)

Really, how is it done?

Many foresee the major stumbling block being tracking the time spent on between-visit work across multiple team members and easily reporting this so appropriate billing can be done. Some electronic platforms for team-based care coordination can make this very easy. 

For many PCMH’s (or practices in the process of becoming one), most of the requirements can be met with the simple addition of an electronic team-based care-planning tool like ACT.md.

Is anyone taking this on in January?

Yes, and you should take advantage of it immediately! ACT.md is already working with practices who have successfully billed for Transitional Care Management (TCM). Toni Apgar, RN, is a care coordinator at one of these practices. “CCM as outlined by CMS is, at its root, simply good patient care,” she said. “We have been providing this kind of care planning and follow up to our chronically ill patients for some time. We find med management especially critical to a patient’s long-term success, along with establishing a personal relationship between care coordinator and patient.  We are pleased that CMS is recognizing the hard work this represents between patient visits, and the positive effect on patient outcomes. We hope other payers do the same.”

In order to execute the plan, each project team member (including the client) had to clearly understand his or her role and their deliverables. At the end of the day, we were hired because the team executed a plan that led to the desired results and exceeded the expectations of our client. The single uniting factor I’ve seen repeatedly across a range of industries and professions is this: high functioning teams are central to success.  What if healthcare had the same structure and accountability with Team-based Care? How do we support the physician or care manager who is often charged as the “engagement manager” for the patient?

Healthcare has an opportunity to apply the team-based models of other professions to the job of patient care. As business theorist Clayton Christensen defines, “The jobs-to-be-done framework is a tool for evaluating the circumstances that arise in customers’ lives. Customers rarely make buying decisions around what the ‘average’ customer in their category may do . . . [rather] because they find themselves with a problem they would like to solve.” Both patients and professionals involved in the care of patients have told me “I just want someone to tell me what I need to do.” Patients want to understand how to get better and physicians want to do what they came into this profession for – to deliver quality care and help people. Delivering on this job requires that providers and patients employ principles of Team-based Care.

Patients Are Like Projects

What if we thought of patient care as we do projects in other professional settings?  These team-based projects would have diverse team members, tasks, plans, and objectives. As in management consulting, the patient project information would be available to all members of the team (in this case, the patient, caregiver, doctors and other healthcare professionals). At any point in time, all members of the team would quickly understand the state-of-play and know how to communicate to drive action. This is Team-based Care. This new care delivery model would help healthcare realize the quadruple aim of care: enhancing patient experience, improving population health, reducing costs, and improving the work life of clinicians and their staff. As I heard from an Oncology center in New England, “when we implemented a Team-based Care delivery model, accompanied by a patient-centered project management tool we reduced the time spent on coordination and communication activities by 30%.” Team-based Care can quickly yield measurable results.

Four Requirements for a Successful Team-Based Healthcare Delivery Model

Requirement 1: Metrics and Visibility to Measure & Improve

New models of care are driven by health quality metrics. To collect this data, organizations have invested in electronic medical records, health information exchanges and population health tools for the purposes of documentation, billing, aggregating data, identifying high-cost populations, and tracking quality metrics. These investments have led to provider dissatisfaction, staff burnout, and patient frustration as all parties are burdened with tasks often detached from care. In a 2014 survey, 68% of family physicians and 73% of general internists said they would not choose the same specialty if they could start their careers anew. As one physician noted, “I can’t believe how much of my time is now spent documenting instead of executing care!” The team-based project model of care would help improve care processes for everyone involved – creating greater efficiencies and higher quality.

In consulting, we always knew the status of the project. Questions such as, “Are we executing against the plan?  Are all members of the team meeting their commitments? Are we on schedule, on budget, and meeting the goals of the client?” could quickly be answered. This data enabled the manager to measure, adjust, and improve team performance to meet commitments. Likewise, Team-based Care would provide new data (e.g., execution to plan, team composition, team loading, patient engagement, etc.) for the healthcare provider and their patients. Such analytics would empower organizations to implement continuous improvement initiatives to refine how care is happening. Knowing the state of play and being able to make adjustments in real-time is critical to delivering reliable healthcare.

Requirement 2: Know the Team

One of the first tasks in launching a consulting project is for the manager to find the best professionals available to study the strategic question of the client. Typically team members were from different offices, had never worked together, and had to quickly understand their unique responsibilities. In a Team-based Care model, all participants similarly understand the composition of the patient’s team. I have a great deal of sympathy for healthcare providers working in today’s environment. There seems to be an ever-increasing range of process pressures, relationships to manage, and technology challenges. A typical primary care physician must coordinate with 229 other physicians across 117 practices. And we see the results: 40% of all malpractice claimsinvolve underlying communications problems.

A large pediatric practice here in New England illustrates the challenge of team complexity. This practice hired a care coordinator to work with the most complex kids within their practice. The coordinator needs to work with various pediatricians, social workers, nurses, community resources, and a range of specialists to provide the best care possible to the child and family. Once a month this team of healthcare professionals meets in person to discuss the plan and define responsibilities. At the end of the meeting the team disperses with few means to communicate, no way to understand what’s happening in real time, and little visibility into the process of care. Handoff drops are commonplace because no one understands if tasks are completed and require dependencies addressed. It’s only when the team reassembles that they fully understand what did or did not happen, and are able to reset the plan.  Kristy Trask, an RN who manages involved cases like these recently stated, “As a care coordinator for kids with complex needs, I need tools to work across all the players supporting the family and child.” Healthcare needs better tools for patient management.

Outside of healthcare, it would be extremely rare for professionals to be without support by the appropriate information technology to manage projects as complex as a sick child. Yet, even in the 21st Century, most healthcare professionals do not have the project management and communication tools to handle a single patient – much less a portfolio of 3,000. Patients often choose their own doctors and specialists. Therefore, different care team members may not know each other, may not have worked together previously, or communicate with each other regularly if at all. In a true Team-based Care model, clinicians, staff, patients, and caregivers could have the ability to know who is on the team, everyone’s role and responsibilities, and interact with each other to move care forward.

Requirement 3: Know the Plan

In management consulting, the central responsibility of the Engagement Manager is to facilitate communication and ensure efficient project execution. In Team-based Care, communicating the plan – including coordinating key activities and identifying responsible owners – is a requirement. With patients moving between different healthcare organizations, communication and coordination presents as a significant obstacle. This is complicated by the fact that health information technology is complex, sensitive, and siloed with little opportunity for easy access and implementation.

Requirement 4: Patient-Centered and Patient-Involved

The core job-to-be-done of healthcare is to help individual patients get better and enjoy the best quality of life as they manage their health. The core job-to-be-done of Team-based Care is to keep the patient and their needs at the forefront. Teams must be mapped around a patient. There must be real-time accountability to the status of the patient’s health. Patients and caregivers should be given visibility to (1) know who is on their team (2) know what the plan is – in a way they can understand and (3) know the current state of play.

The Power of Team-based Care