Value Based Care encompasses several different Population Health Models that were created by the Center’s for Medicare and Medicaid Services to offset the burden of non-face-to-face patient care. Adding these programs to your current practice workflow can also increase your revenue. These models include:
- Chronic Care Management
- Principal Care Management
- Transitional Care Management
- Advanced Care Planning
- Remote Patient Monitoring
Chronic care management is geared toward Primary Care Providers. Patients with 2 or more chronic conditions that are expected to last more than 12 months or until death are eligible to enroll in the model. Steps to meeting the criteria to code for CCM include obtaining the patient’s consent, creating a personalized care plan, communication with the patient, and documentation of at least 20 minutes of care coordination during the month. Care Coordination documentation includes an ongoing review of patient status, and management of diagnoses, referrals, and prescriptions.
- Management of chronic conditions
- Management of referrals to other providers
- Management of prescriptions
- Ongoing review of patient status
Principle Care Management on the other hand is geared toward Specialists. Patients who have a complex chronic condition expected to last at least 3 months and that puts them at risk for hospitalization, acute exacerbation, or functional decline are eligible to be enrolled in the PCM model. The complex condition would, most likely, require frequent adjustments in the medication regimen, diagnosis management that is unusually complex due to comorbidities, and ongoing communication and care coordination between relevant practitioners furnishing care. Like with CCM, you must obtain patient consent and a have personalized care plan.
Transitional Care Management can be coded by both Primary Care Providers and Specialists. TCM helps to improve outcomes after a patient is discharged from a facility and returned to their normal community setting. Two criteria are needed for coding TCM, contact with the patient within 48 hours of discharge and a follow-up appointment with the provider. The follow up appointment needs to occur within 7 days for a high medical decision-making diagnosis or 14 days for a moderate medical decision-making diagnosis.
- Inpatient acute care hospital
- Inpatient psychiatric hospital
- Inpatient rehabilitation facility
- Long-term care hospital
- Skilled nursing facility
- Hospital outpatient observation or partial hospitalization
- Partial hospitalization at a community mental health center
Community Settings include:
- Domiciliary (such as a group home or boarding house)
- Nursing facility
- Assisted living facility
Advanced Care Planning can also be coded by both Primary Care Providers and Specialists. All patients are eligible for this program. The discussion must be a voluntary but can include explanation of advanced directives or assistance in filling out the end of life paperwork. Documentation should include who was present during the discussion and any change in health status or health care wishes.
Remote Patient Monitoring is the newest telehealth offering to patients. It allows patients with at least one chronic condition or an acute illness to use mobile medical devices and technology to gather patient-generated health data and send it to the provider for management of chronic conditions. The most common devices include scales for monitoring weight in the CHF patient, pulse oximeters to monitor COPD, Glucometers to monitor Diabetes, and BP cuffs to monitor uncontrollable HTN. Patients even have the opportunity to use their own wearables such as smartwatches and smartpatches. The patient just needs to have a qualifying diagnosis.