PCCM Answers Our Burning Questions

We asked Annual Conference Sponsor PCCM some questions we thought our members would like to know, and are passing their answers along to you! Here are our questions and the information provided by PCCM:

PCCM coordinates care for patients with chronic conditions. Tell us about your care delivery model.
PCCM provides Physicians with an off-site, dedicated clinical staff employed by PCCM. Under the Medicare regulations for provision of Chronic Care Management Services this staff qualifies as working incident to the Physician. Where a practice may be an RHC or FQHC PCCM’s staff work on-site at the clinic.
PCCM’s service includes identifying eligible Patients, risk stratification based on HCC score (Hierarchical Condition Category), all materials required for electronic or physical capture of Patient consent, initial care plan personalization, 20- minutes of non-face to face care coordination monthly using qualified clinical staff, service coordination and referral, post emergent care consultation, care transition assistance (inpatient to home), full access to PCCM’s, CMS certified, cloud based software platform and 24/7/365 PCCM clinical staff availability. All of these services are included in PCCM’s standard per Patient, per month fee.
PCCM also offers Medication Therapy Management (MTM) via its Simplify My Meds Program. This program combines Medication Synchronization, Multi-Dose packaging and home delivery of prescription and over the counter medications. MTM greatly assists Patients to avoid the adverse effects of medication non-compliance and minimizes Physician’s staff’s time spent tracking and facilitating refills as refills can be facilitated by PCCM staff and using the CCM portal.

How is the practice reimbursed/compensated when working with you?
In January 2015, CMS implemented a new chronic care management code (99490) that reimburses at an average rate of $43 per member per month. For a Primary Care Physician with 200 participating Patients using PCCM services, this results in a $60,000 yearly revenue increase with no upfront costs for the practice. PCCM provides the entirety of it’s CCM service, on-boarding, clinical staff, software, ancillary materials and 24X7X365 clinical staff availability for $18.65 per participating patient per month. PCCM extends the practice 90-day payment terms; so Practices incur no cost associated with implementation or service delivery until well after they have begun being paid for CCM services.
In addition to the new revenue associated with CCM service implementation, CCM drives Patients to the practice for well visits, same day sick, disease management follow-ups, post discharge visits and preventative care needs. Care Coordinators focus on the value of face-to-face patient visits with their providers ensuring the patients are scheduled as needed. Preventative care is scheduled by the Care Coordinators who will also provide patient education on the importance of these essential visits. Increasing preventative and well visits drives additional revenue to all avenues of ambulatory and outpatient care services.

How does your patient on-boarding service work?
Data from a Physician’s EMR or billing system is uploaded via secure link into the PCCM cloud based software and all qualifying Medicare Patients (Medicare Enrollees with 2 or more qualifying chronic conditions) are identified using this Physician Supplied data and then sorted into high, medium and low risk levels using their Hierarchical Condition Category (HCC) score.
PCCM provides contracting Physicians and their office staffs with assistance on-boarding new CCM Enrollees. PCCM will mail personalized, program introductory letters to all identified, eligible Patients; will assist Physician office staff to contact Patients by telephone to introduce the CCM program and, if requested, schedule office visits for those Patients not seen by their Physician in the last 90-days. Where Patients have had an office visit in the prior 90-days and have a current, Physician prescribed plan of care, PCCM can electronically capture the Patient’s consent for CCM services provided the Physician has previously discussed Chronic Care Management with their Patient. PCCM provides Physician practices with all necessary Patient enrollment and education materials, including privacy and consent forms and initial copies of their personalized plan of care. Patients may log onto PCCM’s secure, electronic portal to receive and sign all materials and forms or receive and sign hard copies while at their Physician’s office. PCCM’s Patient Consent materials specifically address the nature of CCM; how it’s accessed, that only one provider can provide CCM for a Patient at a time, that the Patient’s health information will be shared with other providers for care coordination purposes, that the Patient may stop CCM at any time by revoking their consent, and that the Patient is responsible for co-pays and deductibles (Co-pay for CCM is estimated at $8.07 per month and may be covered in the same manner as copayments and deductibles for regular office visits for Patients with Medi-Gap policies).

How do the care teams at PCCM work together to manage a patient’s care?
PCCM works with the Patient to personalize their Physician prescribed care plan and to build in personal motivators, identifiable goals and track-able outcomes and time tables. This care plan will be updated intermittently by PCCM and fully reviewed at least annually by the Patient’s Physician. The care plan assesses the physical, mental, cognitive, psychosocial, functional, and environmental needs of the Patient. Specifically the care plan should include a list of current practitioners regularly involved with the Patient; the evolving status of the Patient’s chronic health conditions, notation of cognitive limitations or mental health issues that impair self-care, assessment of the Patient’s preventive healthcare needs, notation of the Patient’s preferences, choices and values that affect the care plan, a self-identified problem(s) list, expected outcomes and prognosis, measurable treatment goals, symptom management strategies and planned interventions, community and social services’ needs list, notation of care coordination services required, documentation of medication self-management including the review of the Patient’s current medication list, reconciliation thereof, assessment of adherence with prescribed medication regimen(s) and review for potential interactions and allergies.

PCCM clinical staff will provide each enrolled Patient twenty (20) minutes of non -face to face Chronic Care Management Services monthly and which may include (1) on-going medication reconciliation and oversight of the Patient’s self-management of medications; (2) ensuring the Patient is receiving recommended preventive services; (3) on-going monitoring of the Patient’s condition (physical, mental, social); (4) providing education and addressing questions from the Patient, their family, guardian, and/or caregiver(s); (5) providing remote monitoring of Patient physiological data; (6) identifying and arranging needed community resources; and (7) assisting the Patient and their Physician in on-going communication with other community service providers utilized by the Patient.

PCCM will coordinate as necessary with home and community based service providers that help to meet the Patient’s psychosocial needs and functional deficits including providers of home health, hospice, outpatient therapies, durable medical equipment, transportation and nutrition services and will assist in providing referral to other healthcare products and services at the direction of the Patient’s Physician.

PCCM will provide follow-up consultation with all Patients after any known emergency room visits or inpatient stay and will provide, post discharge from an inpatient facility, care transition services for Patients as necessary.

What is the Practice Manager’s role?
Our goal at PCCM is to be the least disruptive to the practice workflow as possible. With that being said, there is some onboarding work required by the practice.
The practice manager will ensure an easy transition and onboarding experience for providers, staff and patients.
Implementation of CCM services includes eligibility determination by PCCM. A list of eligible patients is provided to the practice for review. It is ultimately the PCP’s decision to encourage participation in CCM services.
Once the patient list is reviewed by PCP, then the list is worked by staff in the practice to determine when the patient will be presented with this program. The patient must be presented CCM services at an E/M visit or a Wellness exam. This could be at an upcoming or a newly scheduled appointment.
Once the patient is presented with CCM services and agrees to participate, a HIPAA form and Consent form is signed and faxed to PCCM.
This completes the onboarding expectations from the practice.
An ongoing practice manager expectation is keeping an open line of communication with the practice staff, providers and PCCM staff.

Quality measures drive alternative payment models. How is quality measured at PCCM?
Quality measures are driven by evidence-based interventions based on patient’s chronic conditions and personal health and wellness goals set by the Primary Care Provider and/or the Patient.

Interventions include but are not limited to:
• Personalized care plan with defined goals and treatment plans for each goal to easily track patient progress
• Patient Education related to chronic conditions, medications, exercise and diet
• Providing patients with tools for tracking: Blood pressure, blood sugar, exercise and diet
• Assisting patients with determining Right Care at the Right Place at the Right Time. Driving patients back to the primary care office for non-urgent issues
• Psychosocial, Functional and Environmental Assessments
• Depression screenings
• Community resource referrals
• Behavioral Health and Substance Abuse referrals
• Medication Therapy Management including medication adherence tracking
• Smoking cessation
• Care transition follow up and assessments
• Biometric tracking of vital measures

All activity with the patient is reported back to the primary care provider as needed but at a minimum updated monthly care plans are sent to the practice.