Good afternoon, just for those of you who have already joined us, we're going to give folks just a minute or so to get logged on and we'll get started shortly. Thank you. Well, welcome to part one of our two-part webinar series addressing the use of care management services. The idea for this webinar originated from a Listserv question a couple of months ago, where a member posed a question interested in learning more about starting a chronic care management program. Well, there were multiple responses. It was a very active Listserv, people wanting to know the same sort of thing, like how do I make it happen? And how can it be successful? And what do you do for this, that, or the other thing? So we recognize this particular Listserv activity was our cue to provide you with a better understanding of care management services with some of the operational and clinical knowledge base that the Care Transformation Team hopes to bring to you here. So here we are today. And now it's a big topic and we could talk for a very long time. So what we've decided to do is to break it down into a few parts. Today, we'll be addressing transitional care management and principal care management. In the future webinars series, we'll talk more about the financial return on investment, operationalizing, and we may even then be able to add on additional pieces for specifics for chronic care management, keeping in mind that many of the same principles you hear today will also address chronic care management, some of the workflows. So the other thing, I think this is a good time to point out, whenever you participate in a Listserv, when you receive the initial question, you also will get any responses that people pose. So there's no need to say, hey, I'm following it, I'm watching this information, please send it to me, because that may crowd other people's inboxes. The great thing is, is that Ari from our academy is sending out a summary of Listserv responses on Fridays. So watch for those in your inbox. So with that, let's move along just the usual housekeeping details here. You'll find a link to access the presentation slides in the chat box. So if you click there, you'll see posted very shortly, if it's not there already, a link to today's slides. Feel free to download those for your own reference or to share those with other folks you may know on your team. And then please use the Q&A function to enter any questions you may have. We'll make sure we've left time at the end of the presentation today to answer your questions and even take live questions if you prefer. So make sure, again, you download the slides, put in some questions, and we'll hopefully provide you with a good piece of information to get you started. So with that, care management. It feels like the right thing to do. And you want to do it, but it's like sometimes it feels a little paralyzing almost as to how to get started. So what we hope to do again today is to give you a little bit of the why and the how and the what it takes to make it successful. A little bit about the cost of cardiovascular disease and chronic disease in general. No surprise that it's expensive. It was surprising to me, though, to learn that more than 60% of Americans have at least one chronic condition and of that population, 40% suffers from two or more chronic diseases. And that the chronic diseases as a whole are responsible for 70% of the deaths in the United States. Off to the right-hand side of the screen, what you'll see there is in billions, that's with a B, billions of dollars that are projected for cardiovascular disease costs. You'll see at the very top, that orange line, that's coronary heart disease winning out over the others, but certainly other types of cardiovascular disease, including at the bottom heart failure and atrial fibrillation take up lots of dollars in the healthcare system. This is where disease management programs can really attempt to improve the whole delivery of care to patients that we serve. They have chronic disease and we are able then to provide them better self-care management techniques, patient education, training, individualized care plans, ways in which we can direct them to help them manage their disease and hopefully keep them out of the hospital, keep them from needing escalated levels of care so that the kind of care that they have or they receive or the kind of complications they might have require a less intensive intervention and certainly a less expensive intervention. Interesting to think about the cost of cardiovascular disease. I, myself, with my own background being more hospital-based, I always think of those inpatient stays as being so expensive. In the first column, and you'll see those red circles as they've gone down the rows, you'll see for heart disease, and this is from heart and stroke statistics from 2023's update, that certainly inpatient stays account for a lot of the dollars. Again, this is in billions of dollars. But not to forget about the fact there are lots of other points of care that also require a lot of expenditure, be they ED visits or be they outpatient or ambulatory visits, as well as home healthcare and the medications that people need to take. And then don't forget about the lost productivity or certainly even mortality and the cost of that to the healthcare system. So this is where we think about, again, the kind of costs that we're already experiencing and how better management of these chronic diseases might be able to reduce that cost. So a couple of examples, I think it's always interesting to see distribution of particular types of diagnoses. This particular graphic comes out of DFINITY Health. This represents Medicare claims data from 2022, and you'll see the percentage of the population with a primary diagnosis of heart failure. What you'll notice, I'm here in Michigan and we're just under 11%, but the real winners appear to be, or losers as the case may be, would be Arkansas and Oklahoma with the highest rates. When you look at the distribution of patients in hospitals, it's not surprising that it's concentrated around population centers. But to keep in mind that along with that heart failure diagnosis comes those additional common comorbid conditions such as hyperlipidemia, atherosclerotic heart disease, and hypertensive heart disease that augment the nature of that heart failure and make it even harder to manage. Part of that heart failure management is well known in terms of where the spending occurs. Notably in a particular study that was published in 2022 was that 61% of post-acute care spending occurred after 30 days. So in that 31 to 90 day window following discharge is when over one third of the spending occurred and that was attributed to readmissions and observation stays. So now think about the kind of management you can provide to those patients and how that might in turn reduce those costs to not only to the healthcare system, but especially to the patients and the impact that makes on their lives. A Danish study is highlighted off to the right-hand side of your screen in which where we learned there that if you can follow those process performance measures that we think about in heart failure care, that that can link towards improvements in not only readmission and hospital bed days, but also in mortality. So each of the performance measures that were evaluated that led to that lower risk are listed below, be that heart failure classification to raise the awareness of the level of heart failure that the patient was experiencing, particular medication instruction, exercise therapy, and then patient education as a whole. And if you fulfill more than 50% of those performance measures, you saw again reduction in both all-cause readmission, heart failure readmission, hospital bed days, and mortality. So again, clear benefits from the appropriate kind of follow-up care that's needed for these kinds of patients. That's also true for acute coronary syndrome patients and lipid management. This study was published just a short while ago, earlier this year. And it was striking to me how what we found is that fewer than 30% of Medicare beneficiaries had their LDL checked within 30 days following their MI and their hospital discharge. It also pointed out some of the racial and ethnic disparities, and you can see there in the center the geographic distribution. We in the Midwest have a little bit of room to improve, but certainly no one, again, was really performing better than 36 to 37% of those patients. So lots of room for improvement. These are just two examples of the kinds of patients that you may want to include in your principal care management or transitional care management. Again, just overall, talking about care management benefits, thinking from the patient's perspective, the kind of proactive care that they can receive that's very patient-centered, provides them with education about their disease and about the care plan that we've developed for that their provider has developed for them, the kind of care coordination that they might need that helps to bring the picture all together, and the kind of ongoing management relationship and access support so that they really develop a relationship with one of the members of the care team in the office. Quality measures can be achieved perhaps better. We may have better documentation, improve patient outcomes, certainly as I just pointed out, as well as length of stay reduction and readmission improvement. And then a structured reporting that helps us to collect data by having better documentation. We can understand our performance better. Certainly then there is some revenue opportunity, some benefits when it comes to achieving non-face-to-face service revenue, improving access that leads to either new or urgent care improvements so that patients don't need to access the system quite as often, or that we're aware of the fact that they would benefit from a particular procedure. Let's say it's atrial fibrillation because we've been following them more closely. It also then, as part of that ongoing care management provide it in a more timely fashion. Again, that may be even helping us to achieve certain quality incentives and adding revenue there to the practice. As far as providers go, we do, you know, there is some demonstration of improved communication amongst providers, reduction in some of those messages that have to go back and forth between patients, be they in-basket messages or phone calls. And it may help to achieve a certain quality metric performance if that's part of the compensation plan for a practice or then improved overall patient access and satisfaction because of the kind of relationship and connection they have with their providers. Get that to move forward there. Whoops. Back up. So getting started. If we're thinking about principal care management or transitional care management, these are some of the populations we're going to recommend you start with, that they might be some of the easiest in which to identify and follow through. So there's a group of heart failure patients and the benefits there, the ways in which you might be able to manage them is to help achieve better goal-directed medical therapy, better volume management, and along with that comes diuresis. With atrial fib populations, of course, there's stroke prevention and anticoagulation management. The evaluation for ablation and get them on a more timely path for a more rapid access to care when it comes to ablation. And certainly with coronary artery disease management, as already pointed out, the importance of more effective lipid management, the appropriate therapies to address that. And then certainly for that group of patients, they may have chronic angina or a chronic total occlusion and may need a particular procedure to address that or even those with microvascular disease. Any of these populations could be a very nice population to begin with when it comes to a principal care management or a transitional care management. So for the patient population, you say like, okay, so how do we really get started? If you're going to start with principal care management, you may want to then look at your patient population that you serve and identify that by principal diagnosis, listed here for your reference are some of those ICD-10 codes that can be pulled, knowing that for a transitional care management services, it can be either an inpatient or an observation stay that can trigger it. And the kind of folks you may want to look for are what I sometimes call your MVP, your multiple visit patients, wherein there might be frequent clinic visits or phone calls or portal messages for the kind of support they may need for medication or symptom management. So again, think about that group of patients for whom you can provide better, tighter management of their heart failure. It may be ischemic heart disease, as we pointed out, following an acute coronary syndrome admission or the delivery of PCI or some revascularization, CTO, and again, frequent visits. There's also then atrial fibrillation, as mentioned, as another patient population, wherein a recent hospitalization, now this would be a primary discharge diagnosis of AFib, but could be either inpatient or obscure to trigger the transitional care management. And again, those that may need tighter care have a greater level of need for their management of their disease. So how might we then get started? Let's think about that transitional care management. And this is why we call it hiding in plain sight. If you're the provider seeing patients in the hospital setting, or you're a part of that operational team evaluating this, thinking how you can implement transitional care management may start then by setting expectations with the patient that we are going to follow up with you in about two days or within two days of your hospital discharge, introducing the concept to them when they're still in the hospital, discussing with them the fact that we wanna know how you're doing, we wanna make sure your questions are answered. This is probably also important to help the patient differentiate, that this will be different from the hospital callback because many hospitals, of course, have a callback program. And so coming from the clinic to evaluate as part of transitional care management is different. And this is where an assigned staff person in the clinic setting will contact the patient, see how they're doing, see what questions they have, and you may follow an actual template of reviewing their symptom management, medication reconciliation, et cetera. So how you, once you introduce that to the patient during their hospital stay, then communicate that in some fashion back to the clinic. It may be some sort of referral messaging to the clinic staff so that it could populate a work list for transitional care management, and so that they can follow up in the appropriate timeframe. And it fits very nicely with the usual follow-up care for these diagnoses so that when a patient is seen for heart failure or ischemic coronary problem, they're going to be seen back in the office in that seven to 14 day window that's required for transitional care management. And this kind of tees it up to touch base with the patient to see how they're doing, to make sure that those early questions may be answered that may prevent an early readmission or an urgent need because they haven't fully understood the directions provided to them. And then lastly, making sure that that's documented a nice way might be to include that in your discharge information that transitional care management services will be provided and the patient will be contacted. Now, the workflow, how you might do that then is to move transitional care management directly into principal care management services. So you might take that single condition up here at the top left, that's expected to last at least three months post transitional care management visit as your principal care problem and identify that particular condition. When the patient comes back for their follow-up visit, the provider discusses the principal care management program during that visit. Now, one thing I think I failed to mention and kind of skipped over, if you think about who are the first patients you'll want to provide these services to might be those patients that are your traditional Medicare patients with secondary insurance. Because when you choose that population, it's likely that 100% of the cost will be covered and fewer than 10% of those traditional Medicare patients will not have a supplemental, that secondary plan. Nicole is gonna speak more to those, the revenue end of things and the cost end of things in just a few minutes. But just to point that out, discussing that with the patient at the time of their follow-up visit, that could be the APP or the cardiologist. The patient then needs to agree to participate. Now, it says consent here. We don't want you to think that that's the big fancy consent as though I'm having cardiac surgery consent. This is rather an explanation of the services that we'll provide and the patient saying, okay, that sounds good to me. And then that is documented. So that's where that enrollment or consent information is documented in the patient record. That patient is then enrolled in the principal care management program and the first contact is scheduled with the care manager in the office. In those follow-ups that the care manager provides, you'll want to make sure that that care plan is addressed. So the provider during the follow-up visit, establishes the plan of care for the patient. The care manager now in doing those monthly touch points with the patient, touches on aspects of the care plan. It may also be non-patient, it's non-face-to-face, but it's not necessarily talking to the patient for that whole period of time. It may be reviewing labs. It may be making connections with other care providers, et cetera. And then making sure you've reached the time thresholds documented appropriately in the patient's chart, and then dropping that service on that last day of the month so that it can be appropriately billed. So again, it makes for a very nice transition from that transition care management approach of contacting the patient in the first couple of days, the follow-up visit, the follow-up visit then principal care management is introduced and once you have principal care management underway you continue to touch base with the patient on a regular basis. Now the clinical team activities that follow that are many times those that a nurse would be generally providing anyway in the clinic. What you'll need to do however is to assess the bandwidth of the staff and to understand how it fits within the workflow. But the point to be made here is that many times we recommend that a nurse be the one that performs that principal care management or transitional care management and it fits right within the same sort of workflows and the types of activities that they would otherwise be providing in terms of either phone calls to the patients, answering messages through a portal, communication with providers, coordination of care with maybe other types of services like nutrition or pharmacy, helping them with medications, getting them connected with prevention services, and updating the care plan accordingly. Now who are the best staff that should do the work? I mentioned we recommend it be a registered nurse but whoever you are choosing, be it a registered nurse or perhaps another non-licensed person, they should be have that good patient friendly communication skill right and they should be knowledgeable and experienced in the kind of care being delivered, preferably aligned with that principal diagnosis. So in other words taking somebody that's never heard of a PCI before and saying let's put you in a position where you're helping people understand their care post post MI, you're probably not going to be as effective and that's part of what that aptitude for patient teaching and comfort in discussing medications and other questions the patient may have is so important and that's why a registered nurse is going to give you your biggest bang for your buck in that care coordination skill. They obviously need to be self-directed and motivated. Many times they might be working remotely although that's not necessary and certainly comfortable with technology when it comes to being able to navigate either some sort of a visit virtually with that that patient through the portal or something of that nature. You know keep in mind this could be an opportunity for your staff who have been experienced and working in that face-to-face setting and now are ready for perhaps a more part-time position or something that is done remotely and that that's another way to approach that that kind of care for them. So where to start then in terms of your clinic workflow? I recommend taking a look at what you currently do and this is where you sit down with a few of your staff and actually flow chart out your current process. Make sure you understand how things currently work and you may identify a few other opportunities while you're at it but understand how the process of care works and and map it all out. You'll be surprised what you might learn there. That helps you to understand can you do it with what you've currently got? Do you need more people? Do you need a different kind of group of folks in order to make it happen? Identify where the little catches and bottlenecks might be where time and resources maybe are duplicated or wasted and eliminate those processes that you don't need. Automating wherever you can because you might be surprised how many pieces of paper are still lurking out there. And then actually implement your workflow. Retrain the staff. Make sure that staff know what's going on. So it may be that you have only a couple of people that are actually performing the transitional care or principal care management but make sure everybody knows what's happening because the patient coming into the office doesn't know that only person A or B knows about this particular service. They're going to expect that anybody can answer their questions. So make sure that staff is well-informed and can answer at least some of the cursory questions that may arise or that you have a handout that helps. And then make sure as you've either used this workflow or improved the workflow that you make those ongoing adjustments, evaluate its effectiveness. It's that classic process opportunity, process improvement opportunity that you may have. And then take a look at the number of people that work on each task. Anytime you can reduce the number of people that touch a particular task or particular activity, it will be better. So if you think about then this principal care management as a way in which you have just a set group of folks doing the work, it will be enhanced and it will be probably that much more effective for their patients. They will know that, you know, this particular person is my care manager and they're going to be the ones contacting me. They don't want to necessarily think like, well, it's like person roulette. I don't know who's going to call me. So they'll establish a relationship with the person contacting them and then build that kind of relationship where that care delivery can be more effective. And again, don't forget to use documentation templates, dot phrases, etc. that will help you to standardize and organize your information. I thought it might be helpful to give you some potential scripting for principal care management. Obviously not going to read through it, but this is a way in which you might be able to either print this off, or this is the kind of elevator speech you help your staff to understand, helping to make sure that it's highlighting the ways in which it's beneficial. So in terms of potentially reducing costs for patients, better managing their health, avoiding hospital stays or urgent kinds of visits, which may save them money, better management of symptoms and medications, especially if there are medications that need adjustment or titration, helps you get to bowl for those particular therapies, making sure you have better access to the cardiology team and there's follow-up care that's convenient and makes it easier for patients and enhances overall care coordination. So deliver the care, help the patients anticipate what's going to happen, and then allow them that kind of follow-up that will really enhance their ability to manage their chronic condition. I'm going to hand it over to Nicole next, who can talk more about revenue cycle and operational considerations. Nicole. Yes, thank you so much, Denise. You can go on to the next slide. Right, so we chose TCM and principal care management to start off with because I think what we consistently hear, not about these particular programs, but all of these care management services that they did expand this year as well, that we're still learning about, are the implementation challenges. And many of those do revolve, of course, around our billing, coding, reimbursement, but also as Denise talked about, your resource allocation, the enrollment of education of patients, tracking and documenting those services, the time and all of the requirements, and then having that patient engagement to sustain those programs. So we're going to talk a little bit about the requirements of some of the coding and reimbursement, and then provide some data on how much transitional care management post-discharge, to me, should be a no-brainer, considering those patient populations that we have post-discharge, and with that, why it makes sense to look at these principal care management programs and activities that you already may be doing. Next slide, Denise. All right, so for our transitional care management, this is the purpose from a CMS Medicare perspective, is to improve the transition of care of our patients, and Denise covered many of the why's around that. But this is truly around helping those patients return to the community, manage and coordinate their care for that first 30 days. It works with both the patient, the family, caregivers, other health care providers. The billing requirements are that communication within two business days of discharge, and this can be in a direct contact, a telephone contact, it can be electronic. Electronic is specific to use of a patient portal and documentation around that, so that's that two business contact, so that non-face-to-face service, and then it's the face-to-face service that it supports either moderate or high medical decision-making in seven or 14 days. So seven days is the high complexity, 14 days is the moderate complex patient. It also specifies it must provide medication reconciliation and management, which if you think about how many times a patient is discharged from the hospital, and if you're possibly not doing transitional care management, you get those calls about their medication management and their reconciliation and trying to understand from the hospital as an example what they were discharged on, and the work that your teams may already be doing with some of that. Plus, when your patient may come in for that out-of-hospital visit, they may not have been on the correct dosage or been on the right medications, and that appointment can generally be six to ten weeks out with the provider. So this is creating that mechanism to help with that transition of care to ultimately keep them from having a return admission within that 30 days. Next slide, please. So for transitional care management services, the face-to-face portion is just like an E&M visit, so a regular office visit. It can be performed by a physician, an advanced practice provider, clinical nurse specialist, or a nurse midwife. So it's a licensed professional that is credentialed to bill and is allowed to bill for Medicare, Medicaid services. The non-physician practitioner piece of this can furnish that non face-to-face service as incident two, meaning that two-day call can be provided by your clinical teams, and we'll talk a little bit about that. Next slide. So that interactive contact, you do have to contact that patient within those two business days. Many organizations have nurse navigators in the hospital or care management folks that help in coordination with this effort post-discharge that connects that patient with the ambulatory clinic team to schedule that two-day face-to-face or either to provide the information to the clinical staff so that they know that that patient needs that two-day call. So this talks about what does the term clinical staff mean from a Medicare definition. This is someone who's supervised by the physician or nurse practitioner PA and is allowed by law, the regulation and facility policy to perform or assist in specialized professional services, but you can't individually report a service, meaning bill for a service. It's to address that patient status and needs beyond scheduling. So when you think of transitional care management, it's not just reaching out to them in that two days to schedule their appointment. It's to perform that medication reconciliation, ensure that they have all of their follow-up appointments and care coordination for their post-discharge. You do have to document that two-day service. Many document that in a clinic or notenote. Some EMRs do have transitional care templates or modules that pulls in that two-day contact into your report when you see them face to face. One thing we're often asked is can you report the service if you make two or more unsuccessful contacts attempts in a timely manner and meet all of the requirements of CCM. So say that you have been unsuccessful in that two-day call, but at discharge that patient was scheduled for their transitional care management visit in the seven or ten or fourteen day time frame. The key from a CMS perspective is to document your attempts to reach that patient. You continue trying to contact the patient until you're successful. So that's not really helpful. So you know it's like you have two or more unsuccessful, so if you document that, you can report the service if you continue to try to contact that patient. So it's important to note that if you have a process set up with your discharge planning that the seven or fourteen day visit is scheduled and you've made these two attempts and they've been unsuccessful and you truly have tried to reach that patient in a timely manner, it's documented in a contact note. If you meet the other requirements of the face-to-face service, you can bill for transitional care management. If the face-to-face service isn't within the seven or fourteen day time frame, you can't bill for the transitional care management. So you have your two-day contact, then you either see the patient if they're high complexity within seven days, they're moderate complexity, you see them within fourteen days. Anything over those from the date of discharge is not billable as transitional care management. So interesting enough, we pulled the MedAccess data, so from the MedAxium database to show, and this is 22 data, we haven't fully published our 23 data yet, that shows our transitional care per program designated physician FTE for all programs. So how many organizations that reported MedAccess data are reporting that they're billing for transitional care management? Again, this is that piece where is it in plain sight? So 40 programs, according to our 22 data, reported that they were billing for transitional care management. As you can see, those over that 90 percentile are doing a great job at operationalizing that. Anyone above that median point, or that 75 percentile, I would say, is really capturing their population. So when hiding in plain sight, as Denise mentioned, if you look at running your H&P admission code, so your 99221 to 223, and if you still bill some inpatient consults, which is pretty rare, and you look at those volumes by your providers and by their specialty, and you think about even if you're starting with your congestive heart failure patients, your atrial fib patients, your CAD management patients, what percentage of those admissions within a year would have resulted in a TCM visit? And I would tell you that percentage would be pretty high in our specialty of cardiovascular. Next slide, please. So when you look at TCM and the billing for it, so, you know, this is, we see a lot of advanced practitioners who do that 14 or seven day visit. This is, of course, our work RVUs, the national non-facility reimbursement, meaning we did this in our office setting, place of service 11. Then if you do it in a facility setting, this is the facility professional reimbursement, does not include if you have a visit reimbursement for your technical side of a hospital setting, but this gives you an idea of the reimbursement. What I compare this to is if you have a patient who gets their two day call, they come in and they see your advanced practitioner in 14 days, and then they're scheduled to see the physician at that next visit within that six to 10 weeks, which a lot of times it's hard to get into their schedules at that time. At least they've been seen, they've had this transitional care management visits, the solidifying their medication management, their care coordination, and you build this moderate level, the 99495 for that 14 day visit. If you compare that to an established visit, level four, which is moderate, that's about 1.92 work RVUs and the reimbursement is about $126 for non-facilities. You can see the difference and that this really does support some resources as you're coordinating care and showing that reduction of admissions across your service lines and also other quality metrics, improvement of access to your patients. The documentation requirements, the date that the beneficiary was discharged, the date you made that interactive contact, again, I've seen this templated, the date you furnish the face-to-face and the non-face-to-face, and then of course, your normal E&M documentation around the complexity of the medical decision making, which is what supports that level of service. That two day interactive contact normally includes the date you make the contact, that you reviewed medications, you discussed appointments, you had that contact with the patient, and then they come in and they see the provider, and of course, they document their medical decision making, they're within the timeframe of the date of discharge, and they're able to build that transitional care management code based on their medical decision making. As Denise talked about the conditions that we discussed around if we take congestive heart failure, atrial fib, and we know that that patient could benefit from being enrolled in continued care after these 30 days, is this not a time or an opportunity that as a specialist managing that single complex condition, that we should consider enrollment in principal care management? Next slide, please. So a few more caveats on TCM before we talk about the PCM. I think I covered most of these. Just a reminder, just like any evaluation and management service, it can't be billed in a global service period, so meaning if they have a device implant in our world, those have a 90-day global, those patients do not qualify for a TCM visit. Also transitional care management can be provided via telehealth, audio and video only. So it can't just be audio, it has to be audio and video, but this service can be done from a telehealth perspective. Now, of course, reimbursement may be different depending on the place of service. However, it can be done in a virtual aspect. If that patient has any other visits within that 30 days that are for a separate problem condition, those evaluation and management services are separately billable as well. All right, so principal care management. I believe when we look at all of the care managements as we go through these through our series and continue providing this information on how we could utilize these in cardiovascular programs, principal care management is one that's truly designed for specialists. So when you look at the definition of that, it's similar to all of the care management codes around coordination of care, reduction of hospitalization, decrease of over-utilization and improved patient engagement. Next slide, please. So the PCM parameters, and this is why I think this is something to look at. So you have a patient that comes in for their transitional care management. They do have more than likely to qualify a high-risk complex chronic condition that's gonna last three months or up to 12 months or until the death of that patient. So it's only one condition for this principal care management to qualify. It puts the patient at an increased risk of hospitalization, exacerbation, decompensation, decline, progression, or even death. It requires a disease-specific care plan. Meaning if we look at those examples, congestive heart failure, atrial fib, CAD, it's a disease-specific care plan that we're providing to that patient. Principal care management is a time-based service and it's a condition requires adjustments of medications. And also they have management of conditions that are unusually complex that are due to their comorbidities. So a lot of our patients who have that complex chronic condition also have comorbidities that impact that condition that require ongoing management. It does require a face-to-face visit within a one-year period of enrollment. Obviously, if you had a TCM visit that meets that you saw that patient, then you enroll them in principal care management, which is a non-face-to-face service if provided by your clinical staff. Next slide. So the consent, Denise talked a little bit about, and this is one of those areas that could be a barrier. However, you have the patient there for transitional care management. You're discussing with them their ongoing care plan and treatment. This is not informed consent. Also think about if this is covered in your financial policy and that you have signatures and that it's part of their medical record. During the PHE, we did revamp a lot of our consents to cover virtual service care. However, I do think when you see that patient and you're providing them education, simply talking to them about principal care management that it's a non-face-to-face service if provided by your clinical staff and not your physician or APP, it's there and what it's able to help them with. With any service, a patient does have cost-sharing responsibilities depending on their insurance. So Denise talked about targeting patients with Medicare traditional and a secondary, meaning they probably would have zero out of pocket. We have seen where if they have Medicare Advantage or they have other commercial insurances or they haven't met their deductible and we're at the beginning of the year, they could have some out-of-pocket costs for this as they would any service. So that is part of this and part of that informing. Much of that information is provided in your financial policy. However, documenting a verbal consent at that transitional care management visit that they understand they're gonna be enrolled in principal care management and exactly what that's gonna look like and using some of that scripting definitely helps with this situation. And of course, every patient circumstance is different. I will tell you in working with many organizations and rolling out these non-face-to-face services or virtual, when you look at the percentage of patients who complain or call in about a cost sharing or a bill, not that we don't wanna serve our underserved patients and really support and educate them through this process, the percentage of patients who get an out-of-pocket bill is pretty low. However, they do get a bill if it's their carrier and their policies around that. So these are our codes for principal care management. So these first two codes, the 2-4 is a provider code, meaning that a physician or advanced practitioner would be providing the actual principal care management that non-face-to-face time of 30 minutes. And then there's an add-on code of an additional 30 minutes. An additional 30 minutes. And this is a time threshold for a month. So a calendar month of 30 minutes of time. What we would say is this is your clinical staff providing this, which is those second codes, the 99426 of your clinical staff and having that time threshold of 30 minutes as an example is OneWorkRVU. And you can see the reimbursement in our office setting, it's about $60 in our facility setting. If you're billing hospital-based, you do have that hospital-based reimbursement related to that. And then of course, if you spend more than 30 minutes and you meet the threshold for additional time, there is an add-on code. So when you look at this, this is something that they would be billed for on a monthly basis based on reaching that threshold. What are the activities that your staff are currently performing now that would fall into that 30 minutes? And are you able to capture and document those services, including the time for that and operationalize dropping them a bill? This can go on. They can be in principal care management till death. They can be in it for three months, six months, 12 months, depending on meeting the definition of that care. But this would be an opportunity for those patients discharged in our transitional care management, another way to identify them and operationalize it through your practice. So a care plan example, it's not limited to and is often supported within our documentation notes. So it always includes a problem and medication list, the condition treatment and management goals, which is simply usually the assessment and plan, any education resources or referrals that are provided, any applicable comorbidities. You do not have to manage the comorbidities. However, if those comorbidities, just as in supporting your medical decision-making and care for your patient, are a influence on that chronic complex condition and you're addressing issues with those, you're gonna document that within that. And of course, there'll be in the problem list, your assessment and ongoing interaction. Time, of course, is documented. And then the periodic review and revisions as applicable. So often this is our standard templates within our EMR system, and that you're able to print off, share with as a patient care summary or some type of format. Either they have access to it from the portal or it's something that you give to the patient. We went over documentation requirements a bit. This just gives you a little more around what has to be documented as you go through principal care management. The key here is how are you going to total that time for that monthly care and capture all of these documentation services? Is your system currently supportive of this type of work? Because we have to figure out, regardless if it's principal care management, chronic care, social determinants, or other navigation codes that are available to us, how are we going to capture that non-face-to-face time and support it in documentation? So if you don't have it in your electronic medical record, do you have that IT functional support to create the workflow? Or do you look at third-party options within this care management space that even includes some remote monitoring as well? Few caveats here. Principal care management can be billed by a specialist, even if another provider is billing for chronic care. So oftentimes we'll hear that your primary care networks bill for chronic care management. This is principal care management, and it can be billed by a specialist for that particular chronic complex condition. It also can be billed when your patient's enrolled in remote patient monitoring. The key is that you can't double count time. So what time they're having remote patient monitoring can't be counted toward PCM time. It's time-based monthly service. Again, if your clinical staff is providing it, which is what we would mostly see, then it would be non-face-to-face. So there's no telehealth component if your clinical staff is providing that non-face-to-face or if your provider is as well. But normally it's gonna be the work of your clinical team providing that interactive, proactive phone connections with your patient or portal connections. So when we looked at principal care management in the MedAccess database, they had zero cardiovascular programs reporting principal care management. We pulled the chronic care management just to illustrate, and we will have a series covering chronic care management and other complex care management. Only seven programs reported chronic care management programs. I will tell you, I believe this is because of the challenges of operationalizing this. Coming through the PHE, some of these programs failed within that time or either got put on the back burner. It's obvious that our Medicare physician fee schedule reimbursement is not going to our diagnostic and procedure services. It's going towards these care management services and being proactive towards value-based care with our patients. So I think we have some opportunity here and we just have to figure out how we're gonna operationalize this and the resources that it's gonna take to do that. So key recommendations for success. Consider documentation and time tracking software versus your EMR options. I think that's huge. There are many products within this area. We do have some members who have had success in this area and we hope to continue to share their experiences at our in-person meetings and through webcast as well. Review your existing workflows to identify processes and staff that are already providing key portions or parts of that transitional care management and principal care management. Define their roles and responsibilities. Be sure that they're performing at their top of license. This is something that does require ownership. So if you have a nurse or nurses who can own this program and build this program, it's a way for them to show that they can support resources needed and that there's downstream impacts for our patient. Denise provided us with some scripting. Communication and education is essential to the patient. Our patients like being called. I will tell you how many times are they trying to call our office and we're being reactive as opposed to proactive and how can that improve our phone trees, our access for our patients for those in-betweens, not their visit necessarily, but when they're trying to call or they need assistance with medication or management of their conditions. So how does that help our access? In-basket messages, all of those things we can think about. Collaboration with all departments front end to the back end, meaning I have to be solid on my patients when they're coming in. They have to have the information that they need. The staff has to understand the program and that has to flow through our clinical teams, our providers, and then of course, to our revenue cycle teams to be able to operationalize and capture that revenue. There's a few resources here that have the chronic care management guide does have the principal care management instructions in there along with the transitional care management guide as well. And then we have a part two and I think that's the next slide, Denise, that will be coming and it'll be done by Joel and Anna. And this will be getting into how can you formalize your services for return on investment by focusing on these two areas and what does that look like? So what does it look like from all of the things we talked about, resources, IT, software, all of those types of things, what are the considerations and what does that look like from a return on investment? If you have any questions, you can feel free to type those in. Denise, I don't know if you have any additional comments and we can wait to see if anyone has any questions that they type in and happy to answer. I don't know if I can see the questions. So Ari or June. I can see them as well. I can see them. I don't see any in the box right now. I know again, a lot of information to digest as you're thinking about this, you're thinking about the different items that you have on your plate. This is two sections of care management and I think we have, I counted up to 10 now. So learning about these and figuring out how they're gonna work in cardiovascular, I think is gonna be essential to our programs and I hope we can continue to provide you with valuable information. If you have any questions, feel free to email Denise or I. Denise, anything else in closing? No, just to wrap it up, I think it's been, thanks so much, Nicole, as usual, you're just a wealth of information and I'm always flummoxed by how much there is to know on the money end. I just wanna get it done. So yeah, I'd say that Nicole's point was really well taken that the transitional care management kind of feels like a bit of a slam dunk. We don't mean to minimize that there needs to be some, maybe work redesign or some process improvement around that to evaluate what you're doing, but that is really where it's hiding in plain sight. And the other pieces can go along with that and can flow as a result, but that might be a great place to start. So like anything, sometimes it feels daunting, but if you just dip your toe in the water and get started, you may be able to realize those benefits and then of course, tracking, see how those patients are doing, reporting back to see if you have seen an impact in maybe the number of clinic visits or urgent care or ED visits that those patients are encountering or the ability to get to guideline directed therapies, meet their LDL goals, whatever it may be, can really reap those big rewards. So I think I do see now, cause I can go over. Yeah, so it looks like we have a question. Is the TCM phone call, can this be done by a nurse? Yes. So that two day phone call can be done by clinical staff that's under incident two of the physician. So it can be done by an RN in that clinic area and documented as such by them. Right. And is that, I see there's, do you have any staffing ratios? For example, how many nurse navigators per number of TCM discharge patients? I don't think we have any data on that now, but I'll be interested to see Joel's magic numbers. I'm gonna put a little pressure on him for our next one on the 27th of what does that staffing look like? What does that modeling look like? And what are the considerations? Unfortunately, we don't get a lot of benchmarks, but when you look at volume of calls versus volume of admissions, we probably can come up with some estimates based on that as we look at call center metrics for nurse triage, those types of things. Yeah. All right. I see- Also, can I 48 hour visit from hospital discharge for TCM be telehealth or does it have to be an office visit? So if you're seeing the patient in three days post visit in order for it to qualify for transitional care management, you would have to meet the two day call. So you would still have to meet that non face-to-face piece. And then if you see them within three day, within the seven days, depending on 14 days and it's moderate or high decision-making, it could be TCM or it could be a telehealth visit as well. It just, it depends on if you're meeting all of the requirements around that. Great. Very good. I see we're at the top of the hour. We really appreciate all those folks that have joined us today. And you can feel free again to access the slides that are in the chat, download them. And this will be, has been recorded and will appear in the MedAxium Academy in the coming week or so. So thanks again for joining us. Make sure you're back on March 27th for the Anna and Joel show. They will do a great job in helping you understand more about the value behind doing this in terms of a return on investment. So thanks. Have a great afternoon. Glad you joined us. Thank you. Bye bye.

Transitional care management

Principal care management

Chronic conditions

Patient post-discharge

Disease-specific care plans

Medication management

Reducing hospitalizations

Patient engagement

Care coordination

Healthcare practices