Onboarding Course

A big warm welcome to HTM Consultants team. We're delighted to have you on board, and we hope you're settling in nicely.

When you've finished taking this short course, you will:

About HTM Consultants

Mission, Vision and Values

At HTM Consultants, we offer solutions for our patients:

  • self manage their health conditions
  • provide health coaching
  • patient advocacy 
  • care coordination and intervention 
  • improve patient outcomes

 

Our mission

Continually improve patient care through our commitment to people and help navigate patients through the fractured healthcare system, while striking a balance between intervention and care coordination efforts.
 

Our vision

Transform business practices and patient outcomes through our advanced technology platform and excellent care teams.

 

Our core values

  • Inovation 
  • Compassion
  • Commitment
  • Teamwork
  • Advocacy
  • Organization
  • Priortize
  • Time Management

 

Business Areas

HTM Consultants is a healthcare organization in which our processes and systems are designed with inovation. With a strong foundation in clinical reviews, HEDIS measures, Quality measures, Clinical Practice Incentives, multiple healthcare skills, advanced clinical backgrounds, Medical Billing and Case Management, we have evolved rapidly but responsibly, exploring new business areas as we go, and establishing ourselves in the healthcare environment.


Patients - How we benefit our patients. What our patients say....

Patient Success Stories and Testimonials

Success Story

Care manager completed monthly outreach call to patient.  Patient’s husband recently passed away she continues to have difficulty coping and with depression.  Patient also reported her scheduled eye surgery had been postponed and her eye sight is declining.  Care manager discussed her current eye sight and coping strategies until her next scheduled eye surgery.  Care manager was able to provide the patient with the necessary help as she understood the patient’s needs through their communication and continued to provide grieving support as well as a local resource for grief therapy.  Care manager provided the patient with encouragement to follow up with the resource available and she would help patient with scheduling any appointments if needed.  Care manager provided the patient with counseling/therapy during her time of struggle and giving the patient the encouragement to continue with counseling needs.  Patient expressed her thoughtfulness and compassion.  The care manager was able to provide comfort in a patient going through a difficult situation and will continue to provide her the support and guidance she needs through this lifestyle change.  Had the care manager not be involved in her care, the patient would potentially not be getting the support needed during her time of depression and grieving resulting in a decline in health status.


Success Story

Patient contacted the care manager requesting to be re-enrolled into the CCM program as she has re-engaged with the clinic.  Patient reported she was in need of transportation assistance so she could keep all of her scheduled medical appointments.  The care manager was able to assist the patient with her transportation issues to get to appointments through a local community resource. Care manager also noted the patient has a recent referral to a pain clinic, waiting on pain clinic to provide an appointment date/time for patient.  Care manager will follow up with patient/pain clinic to close referral loop.  Had the care manager not have been involved with the patient prior to her leaving the practice and returning, the patient potentially would be non-compliant with medical appointments resulting in higher rate of ER/hospital visits.

Success Story

Care manager received a call from the patients caregiver and states that the pain medication is not working he still has pain and it makes him very drowsy. He cannot walk because of the side effect of the medication that causes the patient to sleeps 12 hours at night and in the day time when he gets the medication he sleeps until 3pm. Patients mother states that instead of giving him the full 10mg of hydrocodone acetaminophen 10-325 she gives him 5mg. Patient's mother requested a medication change for the patient.  Care manager was able to reach out to the office immediately to help assist the patients mother with a change in medication so the pain could be managed while providing a good quality of life.  The care manager confirmed the medication to be changed with the office staff and it will be called into the patients pharmacy to pick up once filled.  The care manager was able to intervene providing the patient with a better pain management medication to reduce the drowsiness and improve his activities of daily living

Success Story

Patient left a voicemail message for care manager to return call regarding a medication side effect.  Care manager returned the call to the patient and patient stated that she cut her Eliquis 5mg in half because it made her head feel like a marsh mellow and it feels like her head was going to explode when she lays down. Patient reports in the morning she is fine because she is up and about, the problem is at night when its time to go to bed. Patient started the Eliquis 10/5/17 the afternoon following her vascular surgery on both legs;  on the left leg she has one stent and the right leg she has two stents. Dr Reddy at Lorven Heart and Vascular Institute performed the surgery. Patient states that she was up all night and she is not feeling good. Patient states that she was prescribed Amlodipine 10 mg once a day before the surgery and Eliquis 5mg twice a day following her surgery.

Care manager  contacted the office and was assisted with scheduling an appointment for the patient to see the doctor at 2pm.  Care manager reached back out to the patient to confirm the appointment at 2pm. On 10/13/17 Care manager reached out to the patient to follow up from previous day appointment, patient reports she was prescribed Clopidogrel(Plavix) 7mg with Aspirin 81mg that should be taken once a day a long with the Plavix and discontinued the Eliquis and Amlodipine. Patient stated she is feeling fine and was glad she was able to get the medication change thanks to the care manager intervening and helping her schedule an appointment to determine the cause of the medication side effect and ultimately changing the medication.  Had the care manager not have reached out to the patient, the patient may have potentially stopped taking the necessary medication and resulting in a blood clot following a recent surgical procedure.

Testimonials

“I'm happy for this program. I never knew it existed and that at times I call the office and get placed on hold. I'm happy to have a care manager that I will be able to communicate with every month”.   Carolyn 

“I'm grateful for the CCM program and I hope Major continues to follow up with her as stated every month”.    Laura

“I'm really looking forward to Major calling and checking on me and looking forward to updating Major on my progress as I was on the verge of giving up because nobody takes the time out to listen to me and my concerns”.    Betty 

“I'm excited for the CCM program and looking forward to see what else it has to offer on a monthly basis”.      Leroy 

“I'm happy and excited about the CCM program and I feel like I have a mediator to speak out for me regarding my questions and concerns because at times nobody reaches out to me”.     Jean 

“I'm thrilled about the CCM program and happy that someone calls to check on my health status”.   Daniel 

“It's good to have a program like the CCM and it's nice to have someone actually calling to talk to me about my health status and other things I might need”.      Charlote 

What is CCM (Chronic Care Management)? What is an Annual Wellness Visit?

Chronic Care Management and Annual Wellness Visits Explained

Chronic Care Management Definition

Chronic care management encompasses the oversight and education activities conducted by health care professionals to help patients with chronic diseases and health conditions such as diabeteshigh blood pressurelupusmultiple sclerosis and sleep apnea learn to understand their condition and live successfully with it. This term is equivalent to disease management for chronic conditions. The work involves motivating patients to persist in necessary therapies and interventions and helping them to achieve an ongoing, reasonable quality of life.  Patients that have a secondary insurance do not have a co-pay for this service.  If a patient only has Medicare, they may be subject to an $8 per month co-pay for this service.

What makes a patient eligible for coverage under CCM?

  • Beneficiaries with multiple (two or more)chronic conditions


  • Expected to last until patient death with beneficiary at:


  •              - Significant risk of death 

  •              - Acute exacerbation

  •              - Decompensation

  •              - Functional decline


The list includes, but not limited to:


  • Acquired Hypothyroidism 

  • Alzheimer’s Disease & related disorders

  • Anemia 

  • Asthma

  • Atrial Fibrillation 

  • Benign Prostatic Hyperplasia 

  • Cancer, Colorectal 

  • Cancer, Endometrial 

  • Cancer, Breast 

  • Cancer, Lung•

  • Cancer, Prostate 

  • Cataract 

  • Chronic Kidney Disease

  • Chronic Obstructive PulmonaryDisease 

  • Coronary Artery Disease 

  • Depression 

  • Diabetes 

  • Glaucoma 

  • Heart Failure 

  • Hip / Pelvic Fracture 

  • Hyperlipidemia 

  • Hypertension 

  • Ischemic Heart Disease 

  • Osteoporosis 

  • Rheumatoid Arthritis /Osteoarthritis 

  • Stroke / Transient IschemicAttack


What Services Are Included in CCM?

CMS specifies that CPT code 99490 may be used to bill for “non-face" time follow-up care outside the office.” There must be at least 20 minutes per month of non-face-time follow-up care provided to eligible Medicare patients outside the office each month, including such activities as:

  • Creating the care plan
  • Discussing the care plan with the patient 
  • Reviewing patients chart to identify gaps in care
  • Medications and therapies 
  • Charting
  • Scheduling phone-based and other non-office encounters
  • No partial CCM services can be billed, it must be 20 minutes or more.  Under 20 minutes can not be billed

How Does CCM Benefit Patients?

As a patient-engagement program, CCM builds “buy-in” with patients.The program and its various services enhance shared decision-making between the physician and patient around their health issues.In addition, since monthly phone check ins occur more frequently than the typical schedule of office visits, CCM adds better visibility into patient compliance with the care plan. Because of the frequency, it is possible to identify issues earlier; if adjustments are needed to a patient’s care, the physician and care coordinator can intervene promptly.

How Does CCM Benefit Physicians and Their Practices?

Monthly CCM calls also tend to reduce the number of callscoming into the office from patients each day; such inbound callsrelated to acute issues to nursing and other staff are not eligible forcompensation, while adding up to a significant number of hours perweek. On the other hand, the proactive outbound monthly calls fromthe Chronic Care Coordinator help the provider get ahead of issuesbefore they become crises, and have the advantage of beingbillable.

Monthly calls by the Chronic Care Coordinators into the patient’s home allow more visibility into the patient’s home environment and its effect on the patient’s health. 

Finally, CCM facilitates the transition to outcomes-based compensation, the standard the CMS wants to apply in the near future.The time is coming when physicians will be reimbursed at a higher rate when they can demonstrate fewer patient hospitalizations, lower costs of care, more positive outcomes and greater patient satisfaction.CCM systems help a provider demonstrate outcomes.

Billable Providers Requirements

Patients new to practice or physician hasn’t seen within past 12 months”, provider needs to see patient with one of these before enrolling into the CCM program:

- Annual Wellness Visit (AWV)

- Comprehensive E/M

- Initial Preventive Physical Exam (IPPE)

The practitioner does not need to discuss CCM at this visit for us to enroll patient over the phone into the CCM program after this visit.

Comprehensive Care Plan

  • Problem list

  • Expected outcome and prognosis

  • Measurable treatment goals

  • Symptom and medication management

  • Planned interventions and identification of individuals responsible for each intervention

  • Schedule periodic review and care plan revision

  • Community/social services ordered

  • Agency specialists/services (outside the practice) who will direct/coordinate

Managing Care Transitions

Between health care providers/settings

  • Include referrals to other providers

  • Providing follow-up after emergency department visit

  • After discharge from hospitals, skilled nursing facilities (SNFs) or other health care facilities 


Other Coordination Opportunities

  • Coordination with home and community-based clinical service providers as appropriate

     

  • Communication to and from these providers 

  • Methods are subject to HIPAA

  • Enhance communication opportunities for patient and caregivers

Documentation

Clinical record includes:

- Comprehensive care plan established, implemented, revised (when necessary) or significantly monitored

- Care plan for each chronic condition with measurable goals

- Beneficiary’s prior permission documented

- Beneficiary may terminate at any time

- Care plan needed every CCM month

Enrollment:

We follow a strict guideline when enrolling patients into the CCM program based on the following criteria:

  • Eligible patients seen in the last 12 months
  • Eligible patients that have Medicare AND a secondary insurance 
  • Eligible patients that have a high risk score
  • All other eligible patients that have Medicare

What is an Annual Wellness Visit?

An Annual Wellness Visit can be defined as a detailed, question-based assessment of a patient’s current health and risk factors. Once a year, patients meet with a clinician to identify at-risk areas. These visits are different from regular annual doctor’s appointments and are followed by counseling to help patients reduce their health risk factors.

Some of the elements covered during anAWV include:

- Review of medical and family history

- Develop or update a list of current providers and prescriptions 

- Health risk assessment 

- Height, weight, blood pressure and BMI calculation

- Cognitive Health Assessment

- Personalized health advice

- A list of risk factors and treatmentoptions for the patient

- A screening schedule for appropriate preventive services

A Personalized Plan of Preventive Services (PPPS) is then developed for the patient, providing them with all the necessary tools and resources required for dealing with any risks or current health problems. Medicare is actively encouraging both patients and providers to take advantage of this service by not only making them completely free for patients, but by also providing financial incentives in some cases.

        HEALTH RISK       ASSESSMENT 

•Demographic data 

•Self-Assessment of health 

•Psychological risk and risk factors 

•Behavioral risks 

•Activities of Daily Living (ADLs) 

•Instrumental Activities of Daily Living (IADLs) 

KEY       ELEMENTS

•Assessment of medical history (including familial risk factors) 

•Psychological screenings (depression, etc.) •Frailty assessment/Functional Capacity •Assessment of fall risk including home safety •Cognitive assessment (direct observation and caregiver report) 

•Advanced care preferences

IDENTIFYING AT RISK PATIENTS

•Living alone in community 

•Increasing weakness 

•Memory complaints 

•Six or more chronic medications

•Involuntary weight loss 

•Worsening mobility 

•Five or more chronic conditions 

•Three or more hospitalizations

CLOSING GAPS IN CARE

•Review chronic conditions 

•Update immunizations 

•Personalized care plan  Highlight preventative services 

•Medication  reconciliation •Identify in-home care needs 

•Advanced directive/ POLST update 

•Specialty referral as needed

Patient Advantages

With Annual Wellness Visits focusing on prevention rather than intervention, patients are given the opportunity to take an in-depth look at how well their current treatment plan is progressing and address any issues that may have come up. This provides an unparalleled opportunity for patients to raise any concerns, if needed, about where they need more care. Detailed assessments allow patients and clinicians to determine if there are any current health and risk factors that are not being adequately addressed, and will follow up with counseling to help reduce any risks if necessary.

Some of the highlights of Annual WellnessVisits for patients:

- They are completely free

- Include a Personalized Plan ofPreventive Services (PPPS) and when to receive them

- Center around coaching them in reducing potential health risks

- Promote prevention rather than intervention

- Do not include a physical exam

Physician Advantages

Annual Wellness Visits are actually interesting to physicians as they quite simply:

- Provide an extra service to their patients

- Generate additional revenue

- Allow for closer ties to patients and their health

- Meet many MIPS requirements along the way

- Assess the current treatment plan without focusing on trying to diagnose new issues

How the Care Coordinator can complete the Annual Wellness Visit and CCM services at the same time:

- The Care Coordinator will help schedule patient AWV appointments

- The Care Coordinator will complete the necessary assessments with the patient prior to the scheduled visit

      - The patient can be emailed these documents to complete as long as they are received back to the care coordinator BEFORE the scheduled appointment 

- The time spent completing these assessments will count toward the 20 minutes of CCM services.  

Must Know Resources

Quality Standards

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.

Procedures

Internal Company Communication and Time Tracking

We use Bitrix24 for internal communication and time tracking.  You will get an email invite for Bitrix.  You will use Bitrix for the following:

- Calendar to enter your work time and days you request off

- Internal communication with all team members 

- Instant messaging to other team members

- Complete Tasks assigned

- Task assignments

- Meeting invites/Events

- Announcements

- Company updates or changes

- Limited company documents

- There will be an "External Sites" tab on your left side menu with a link to the team website where you will find all the sites that our team uses regularly. 


External Team

Team Communication:

  • SLACK

Used to communicate with external partners on the TimeDoc team ONLY


.

Internal Team 

Team Resources:

  • Dropbox

Used to locate all the necessary resources/documents for all members of the team

- Care Plans

- Community Resources

- Patient Engagement

- Patient Assessments

- Patient Education

- Care Coordination Guides/Tips

- Call scripts

-Training documents

- Articles

Software Platforms

Software Logins:

  • TimeDoc - CCM
  • HumHealth -CCM/AWV
  • xCare - CCM/AWV
  • Keeper Vault - TimeDoc platforms login information
  • Passworks - All platforms login information


HTM Consultants Phone System

We currently use the application "TalkRoute" downloaded on your smartphone.  You will be assigned a phone number for each practice you work with.  That number will have a caller ID setup to show the person you are calling what practice you are calling from.  No patient or practice will ever have your personal cell phone number. DO NOT download this until instructed to do so by your trainer.

How to request training?

Our Learning and Development teams are highly adaptable and accommodating. Here's the procedure to request them for a specific training:

- You will be invited to join HTM Consultants Coggno University

- You will have the ability to request training and complete assigned training


Welcome to our team!

Engage

Angie Cardwell, LVN

located in Texas

Care Manager

Trainer

Regional Sales Manager

Rebecca Wood, LPN  

located in North Carolina

Care Manager/Enrollment Specialist

Trainer

Regional Sales Manager

Meet your advocates

Angie Cardwell, LVN and Rebecca Wood, LPN are your new advocates. They are here to help you get to know the ropes. If you're looking for help or advice, they can either help you directly or point you in the right direction.  With Angie and Rebecca as your advocates, you'll be able to get coordinating in no time.

Angie and Rebecca have years of experience in the healthcare field and case management, and now head up the training department. You can reach out to them through our communication platform - Bitrix24.

Execute

Meetings

Here are a few golden do's and don'ts for meetings:

a) State views and ask genuine questions. This enables the team to shift from monologues and arguments to a conversation in which members can understand everyone’s point of view and be curious about the differences in their views.

b) Share all relevant information. This enables the team to develop a comprehensive, common set of information with which to solve problems and make decisions.Use specific examples and agree on what important words mean. This ensures that all team members are using the same words to mean the same thing.

c) Explain reasoning and intent. This enables members to understand how others reached their conclusions and see where team members’ reasoning differs.

d) Focus on interests, not positions. By moving from arguing about solutions to identifying needs that must be met in order to solve a problem, you reduce unproductive conflict and increase your ability to develop solutions that the full team is committed to.

e) Test assumptions and inferences. This ensures that the team is making decisions with valid information rather than with members’ private stories about what other team members believe and what their motives are.. This ensures that everyone is committed to moving forward together as a team. Discuss "undiscussable" issues. This ensures that the team addresses important issues that are hindering its results and that can be resolved only in a team meeting.