Quality Standards for Nursing/Care Coordination Services
CMS Stance – you can count time spent trying to reach the patient, even if you were unsuccessful, but it cannot be the whole 20 minutes.
We do not count more than 5 minutes of failed phone call attempts towards the 20 minute requirement.
You can count time spent reviewing the patient’s chart, but it cannot be the whole 20 minutes.
You do not have to reach the patient on the phone to fulfill the monthly service. But you do have to add “significant value” to the patient in some form.
There are many ways in which Care Managers can add value to patients. Care coordination activities like the following can add “significant” value (if provided appropriately and with quality) and don’t necessarily involve directly interacting with the patient:
- arranging community and social services,
- sharing health information with other members of the care team
- reviewing NEW medical information including medications
- creating/revising patient-centered care plans, etc.
- Closing a referral loop-this includes: confirming visit was scheduled, confirming patient was compliant with scheduled appointment and calling the specialist to confirm they have faxed over patient’s office visit note to your assigned provider
- Identifying past due immunizations/screenings
- Identifying when an annual wellness/physical due
- Identifying HEDIS Quality measures compliant/non-compliant
- Follow up on recent orders
- Follow up on Transition of Care
- Follow up on treatment plans
- Confirming necessary/future appointments have been scheduled
- Confirming visit compliance
- Communication with home-based and community-based providers getting updates on patient’s current health status and identifying GAPS in CARE or deficits to be addressed
- Outreach for educational resources (patient literature, community events, health fairs, classes)
- Follow up with caregivers/support system
- Referral recommendations
- Identifying over-utilization or under-utilization of services
- Identifying use of inappropriate services or level of care
- Follow up on Durable Medical Equipment needs/orders, confirm delivered to patient
- Identify out of range vitals, BS readings, high cholesterol lab values, etc
- Identifying a need for behavioral interventions, pain management or psychological therapy based on frequency of claims/visits presenting these issues
- Identifying when a patient is managing his/her care by reduction in ER visits/readmissions, longer periods of stable conditions, improved patient quality of life, patient shows more confidence in self-care management by having chronic conditions “under control” through medical chart reviews and care coordination with other members of the care team and caregivers
- Remote patient monitoring via secure messaging communication providing them with daily/weekly/monthly tasks or goals
- Provide guidance and support on personal issue the patient may be experiencing
- Complete Monthly Metrics
While you do not have to interact with the patient every single month, you do have to interact with the patient frequently. Our Care Managers at least leave the patient a voice mail every month, assuming the patient has not instructed them to do otherwise. Generally speaking, the Care Managers are interacting with the patients as frequently as the patient will allow according to their preferences and availability. Care Managers approach patients to gain self-control over their health by providing engagement and encouragement for shared-decision making.
Care Managers will dis-enroll a patient if it is found that the program is not beneficial to the patient and/or the patient is not a good fit for the program to avoid unnecessary charges to the practice and patient.
Time documented by Care Managers that do not count toward the 20 minutes of CCM services will be excluded. All documentation will be entered immediately upon completing services.
Care Managers will attempt to reach out to patients within 48 hours of enrollment to welcome them to the program, provide additional details of the program structure and provide them with their contact information.
Care Managers do provide support for caregivers upon notification of the death of their loved one and follow up, if necessary thereafter, to help assist with continued support services.
Care Managers that provide assistance with enrollment discuss in detail the cost-sharing involved in the CCM program, obtain verbal consent and explain the structure of the program and the role of the Care Manager’s relationship with the patient. Patient’s that state they wish to discuss the program with their provider first, will not be enrolled until the practice/provider has given the consent to the Care Manager to begin services.
Care Managers give verbal and/or written (via secure EHR communication) report directly to the practice staff Nurse/Medical Assistant regularly regarding patient issues that need additional attention as well as provide them with updates on patients with significant changes.
Care Managers regularly provide patient direction on when to contact the practice for Urgent issues and call 911 for emergency situations. The Care Manager will contact the practice immediately if they are on the phone with a patient with an urgent need.
If a patient enters Hospice care, we will dis-enroll the patient from the program as it is no longer effective for the patient.