2022 California Council of Community Behavioral Health Agencies (CBHA) Conference

Telephonic Care Management Program for Patients with Medicare

In this important issue on care for the elderly in Behavioral Health News, we hope to highlight the success of our telephonic care management service to the aging population at The Institute for Family Health’s (IFH) network of community health centers in New York City and upstate New York. Innovative approaches to addressing the physical and behavioral health needs of the elderly are critical at a time when federally qualified health centers (FQHCs) face cuts to funding and must adjust to a restructured healthcare delivery system.

Chronic Care Management (CCM) is a telephonic care management service targeting the needs of patients with chronic conditions and Medicare insurance. The Center for Medicaid and Medicare Services (CMS) introduced CCM in January 2015 as a separately billable non-face-to-face service. The goal is to improve Medicare beneficiaries’ access to chronic conditions management within primary care, thus reducing the rate of functional decline and improving health. FQHCs were able to bill beginning January 1st, 2016, and IFH began enrolling patients in December 2017. Patients with original Medicare have not traditionally qualified for reimbursable care management programs at FQHCs, creating additional burden on physicians to coordinate their care. IFH is one of very few FQHCs around the country implementing CCM, and we believe other community health centers can learn from our challenges and successes.

IFH’s Care Management program has existed since 2014. Care Navigators provide support to patients with multiple chronic conditions, many of whom face significant social barriers to engagement in the healthcare system. Service components include ongoing assessment and care planning. When we began developing CCM in December 2017, we felt it was very important that it be well integrated into our existing care management infrastructure. We wanted our CCM Navigator to be able to route patients to in-person support if necessary, and to be included in weekly group supervision. We also wanted to utilize the same panel management tools built for in-person navigation. We did have to accommodate some programmatic differences. CCM is conceptualized as a ‘service’ by CMS, as compared to the ‘program’ model of our in-person care management, meaning it assumes lighter touch services over a shorter period of time. The service itself is provided via phone and not meant to exceed 20 minutes per month. It is meant to support primarily patients with only Medicare, and the marketing materials from CMS target patients 65 and older.

As a safety net health center, we provide care to a medically underserved population. We serve anyone who walks through our doors, regardless of their ability to pay. It is no surprise that our CCM enrollment is a reflection of the population we serve. Fifty-eight percent of patients who have enrolled in CCM are dually eligible for Medicare and Medicaid, and 55% are 65 years or older. This means that the majority of the patients we’ve enrolled have income at or below the poverty line, and almost half are disabled, as opposed to over the age of 65. Our patients’ racial, ethnic, and economic circumstances increase health disparities that impact engagement in the healthcare system and increase risk. We recognized the development of CCM as an opportunity to impact these disparities for our Medicare population by increasing the uptake of prevention, including Annual Wellness Visits (AWVs) and cancer screenings. Given CCM’s limits on engagement, focusing on gaps in care for of our disabled and aging patients allows us to implement a lighter touch model among a high risk population. A telephonic model also allows us to provide remote opportunities beyond limited clinical space, and we are proving we can meet the demands of our patient population without having to add expensive workspace into low-resourced clinics.

To optimize outreach, we created a registry in our electronic medical record that identified approximately 5000 patients as eligible for CCM. Patients are added to and removed from the registry automatically due to insurance and diagnostic changes. Recognizing the ineffectiveness of cold-calling our patient population, we organized outreach to patients both overdue for their AWV and with a future scheduled appointment within 30 days. Not only did this increase conversion rates from outreach to enrollment and improve our efficacy, it targeted our enrollment to patients overdue for valuable preventive screenings, giving us the opportunity to impact population health. If the patient chose not to enroll, the call still served as a reminder for their visit and the visit itself was converted to an AWV. In our eighth month of program implementation we shortened outreach to 30 days, decreased the number of patients outreached each month, and increased the number of attempts made. We saw a 4% improvement in conversion from the previous month. To date, 157 patients have enrolled in CCM.

Since our outreach strategy was predicated on the importance of the Medicare Annual Wellness visit, it’s important to understand the contents of this visit and its associations with prevention. The Medicare Annual Wellness Visit is a yearly appointment with a primary care provider to create or update a personalized prevention plan that helps prevent illness based on current health and risk factors. The provider checks vitals, gives a health risk assessment, and reviews functional ability and level of safety. They learn about medical and family history, create a list of providers and medications, and develop a 5-10 year screening schedule. This visit has strong implications for behavioral health, as the patient is screened for cognitive impairment such as Alzheimer’s and other forms of dementia, and depression. They are provided with health advice and referrals to health education and/or preventive counseling services aimed at reducing risk and promoting wellness.

Our chronic care navigators develop care plans with enrolled patients that focus on gaps in care and, as a result, we have made significant progress in closing these gaps. AWV completion for enrolled patients has increased 11.44%. CCM enrolled patients complete their AWV at a rate of 82%, compared to 73% for CCM eligible, and 42% for the total IFH population. Cervical, Breast, and Colorectal cancer screening rates have increased for those enrolled in CCM by 5%, 11% and 12% respectively.

One of the ways in which we identify risk within our patient population is through a hospitalization risk score, generated by a predictive risk model in our EMR. We want to enroll those at medium to high risk so we can perform interventions that mitigate readmission. These interventions include case conferencing with hospital discharge teams and skilled nursing facilities, coordinating home care, scheduling follow-up visits in primary care, and coordinating specialty appointments. Navigators also review safety plans telephonically for patients with suicidal ideation. 15% of CCM enrolled patients have at least 76% risk of hospital admission, compared to 7% of the CCM eligible population with this high level of risk. We have observed an average decrease in risk of 16% after enrollment in CCM. By enrolling appropriate patients, we more effectively utilize limited resources.

A key challenge is the low reimbursement rate for CCM as compared to Health Home Care Management, with a potential difference of up to $320 per patient per month. Due to low rate and low touch, the panel size for CCM is over double what it is for face-to-face care management. We acknowledge the limitations of this service to patients who have access to telephonic communication, although we try to work directly with proxies and caregivers if access is a barrier for the patient.

In the future we hope that enhancements to our electronic medical record will improve usability of the patient portal, improving care plan sharing and communication beyond the telephone.

We are currently building assessment tools specific to elderly and disabled patients that complement the contents of the AWV, capture the social determinants of health, and better inform our interventions, for example elder abuse, financial strain, food insecurity, and transportation needs. There is potential for us to align our efforts with telemedicine in the future, a very exciting prospect given the isolation faced by many of our elderly and disabled patients. We also plan to adapt CMS’s marketing and educational materials to our patient population.

Addressing the physical and behavioral health needs of an aging population requires innovative and adaptable approaches. By reducing physician burden within safety net health centers, aging patients can remain with their primary care provider longer, delaying the need for more specialized or institutionalized care with limited availability. When we identify risk and focus on intervention, not only do we support our aging patients but we support our health center infrastructure and its ability to provide quality care to all patients.

Katie Bierlein, LMSW, MPH, is Director of Care Coordination. Michaela Frazier LMSW, CCM, is Vice President of Social Support Services, at The Institute for Family Health.

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