Care Coordination and Chronic Care Management: The New Reality

By Dr. Steve Phillips

There is a great deal of activity around acute case management, post-acute care coordination without an apparent consistent model throughout the entire healthcare system. This leads to fragmentation of services, untoward gaps in care and waste within the delivery process. The adoption of a model for the assessment and management of acute and post-acute care patients that is supported across the entire health care landscape is needed. This requires champions within the disciplines of medicine, nursing, pharmacy, social work, occupational and physical therapy. These various champions must be capable of representing the care settings within the hospital, home health and nursing facilities.

The CMS Chronic Conditions among Medicare Beneficiaries 2012 Chartbook shows the impact of multiple chronic conditions on resource use among Medicare fee-for-service (FFS) beneficiaries.

• Sixty-three percent of those with six or more chronic conditions were hospitalized one or more times, compared to 4 percent of those with 0 or 1 chronic conditions
• Forty-nine percent of those with six or more chronic conditions received post-acute care, compared to less than 1 percent of beneficiaries with 0 or 1 chronic conditions
• Seventy per cent of those with six or more chronic conditions had one or more Emergency Department (ED) visits, compared to 14 percent with 0 or 1 chronic conditions

Those beneficiaries with more chronic conditions account for a disproportionate share of hospital readmissions:

• 6 or more Chronic Conditions 70 percent
• 4 to 5 Chronic Conditions 20 percent
• 2 to 3 Chronic Conditions   8 percent
• 0 to 1 Chronic Conditions   2 percent

Resource utilization reflects the cost to a health care system and the disease burden that multiple chronic conditions have on patients. These burdens can be reduced with effective care coordination. The use of chronic conditions instead of utilization, such as in-patient admission or ED visit, has the potential of promoting better care coordination. This can lead to a more proactive model of care coordination at a point in time when it can prevent both in-patient admissions and ED visits. The use of chronic conditions can further risk stratify those patients most in need of comprehensive assessment and care coordination.

Another segment of the patient population to include in a comprehensive care coordination program is those with cognitive impairment. Medicare spending more than doubles when cognitive impairment is present, either alone or in combination with other chronic conditions.

Individuals who are eligible for both Medicare and Medicaid are vulnerable to poorly coordinated care. These individuals use substantially more health care resources, including in-patient hospital care and ED visits, than Medicare beneficiaries who are not eligible for Medicaid. Although they make up only 19 percent of the Medicare FFS population, they were responsible for 34 percent of Medicare FFS spending in 2010.

The Agency for Healthcare Research and Quality (AHRQ) Care Coordination Measure Atlas (2014) can serve as a reference for what constitutes the hallmarks of a comprehensive assessment of an at risk patient population. One of the foundational care coordination activities discussed in the Atlas is assessment of patients’ needs and goals, which is defined as “determining the patient’s needs for care and for coordination, including physical, emotional, and psychological health; functional status; current health and health history; self-management knowledge and behaviors; current treatment recommendations, including prescribed medications; and need for support services.” This comprehensive assessment is essential to addressing patient needs and relevant to all other care coordination activities.

The creation of a proactive plan of care is another essential care coordination activity described in the AHRQ Atlas. A care plan tailored to the patient’s needs and based on the comprehensive assessment should form the foundation for care coordination efforts. It should reflect current and long term-needs and goals for care and specify the types and frequency of planned health, rehabilitation and mental health treatments as well as medications, home care services and supports, and other services. It should also identify who is responsible for providing each service and flag critical issues that would trigger a care plan revision. In addition, the process of developing the care plan should involve the individual and family members, if appropriate, to ensure that it reflects their values and preferences.

To ensure care coordination success this knowledge must be shared amongst all participants in the patients’ care. Examples of this sharing or access to the care coordination plan of care includes: Patient/Physician, Primary Care Provider (PCP)/Specialist, PCP/Hospital, PCP/Post-Acute Providers and Patient/Family.

Another opportunity for enhanced patient revenue is the newly created Chronic Care Management CPT Code 99490. This requires 20 minutes or greater non-face to face encounter time over a 30 day period of time for any patient with two or more chronic conditions. On average 55-65 percent of a typical Family Medicine or Internal Medicine outpatient clinic qualifies for the new Chronic Care Management service.