The Evolution of Connected Care
Dr. Sam Clemmons, Chief Medical Officer - Eques Health
Chronic Care Management (CCM) is a service that was launched in 2015 by CMS allowing healthcare providers to be reimbursed for services rendered to Medicare patients telephonically on a monthly basis. The service was developed as a means to care for an aging population in a more efficient and effective way. A large study published in 2017, supported by CMS, confirmed the efficacy of the program in keeping patients healthier by preventing unnecessary ED visits and inpatient admissions while saving $800 annually per Medicare Beneficiary. An important byproduct was a significant boost in provider revenue. Due to the overwhelming success of the program, several other programs have evolved including Remote Patient Monitoring (RPM), Behavioral Health Initiative (BHI), Remote Therapeutic Monitoring (RTM), and Principal Care Management (PCM). More recently, CMS has developed new code sets for Community Health Initiative (CHI) and Principal Illness Navigation (PIN). An expansion of code sets in RHCs and FQHCs in 2024 further shows CMS’s intent to expand this sector of healthcare to improve the patient care experience, address socioeconomic needs of the Medicare demographic, improve healthcare logistic efficiencies, and enhance health equity in a growing population .
As a physician who has practiced clinical medicine over 25 years and has played a dual role as a physician executive during a large portion of my career, I can safely say that it not easy implementing new modalities into our healthcare system. Having practiced in the day of paper charts. I remember the pushback from providers and ancillary staff as we adopted Electronic Health Records (EHRs). I often heard, “we are spending all of our time on a computer, not with the patient.” As time passed and a new crop of healthcare workers has sprouted, EHRs are now the norm and are accepted by the overwhelming majority.
Along comes CCM, RPM, BHI, etc. More acronyms and more new things to learn. Again, pushback and rightfully so. Providers, clinical staff, billing staff, and payer staffs often are not familiar with these abbreviations, have no concept of the benefit of the services, and frankly have no interest in learning about the services. Medicare has embraced these services as much as any modality I have seen in my career yet many healthcare workers refer to the services as “the monthly phone call” as if referring to a telemarketing call. I have even heard the word “scam” used. How do we overcome this? Educate the providers, educate healthcare staffs, educate patients, educate billers and educate insurance companies. Will this happen overnight? Absolutely not but it will happen with time. What are the obstacles, how do we provide the education, and how do we create a successful program?
1. Understand the patient demographic we are caring for—Medicare patients are an aging population, often have multiple chronic conditions, and frequently have complex socioeconomic needs that are very difficult to assess during a clinic visit that lasts 15-30 min. Connected Care was created as means to keep the patient in a “care setting” even when the patient is not in the clinic or hospital. As mentioned, it is about the wellbeing of the patient and for the patient to have an “advocate” while navigating a very complex healthcare system. Medicare patients have a set of rules that CMS established by law for payment terms.
2. Understand that Medicare established eligibility requirements—Care Coordinators did not. Providers did not. Outreach specialists did not. Office staff did not. Private Insurance companies did not.
3. Understand the enrollment process—Enrollment is most effectively completed by Outreach Specialist trained to speak with patients, obtain consent, and make patients aware of the manner Connected Care Services work. Medicare created a system allowing either verbal or written consent for a service that may require patient responsibility for applicable deductibles or copays. An outreach specialist enrolls the eligible patient after providing a scripted consent. Dealing with a population that often naturally has declining memory, whether consent is written or verbal, the hallmark Medicare supported 2017 study showed that only ~50% of enrolled patients will remember signing a consent. So a cycle begins—patient is enrolled, satisfied and excited about the service, a bill comes, the patient doesn’t have a clear memory, patient complains, and someone is to blame. Along comes education. Educate all who are involved with the patient from the front office staff to the billing staff that this will happen. Are there solutions? Recorded conversations don’t reduce the incidence of the forgetfulness but certainly can “jog” the patient’s memories and be a support for “proving” that the patient was in fact consented.
4. Understand the program was created for attrition—The consent assures the patient that he/she can disenroll at any time. Some patients will. Some patients will feel like they are “too healthy”, some will be disgruntled with deductible or copays, and some will transition to different care settings such as a nursing home or a new city. 10-20% attrition is not unexpected. If there is less attrition, the enrollment process has probably not been as effective as it could be.
5. Understand that Health Equity is Paramount. Regardless of income status, race, ethnicity, urban or rural, all eligible Medicare patients are entitled to be offered enrollment. To not do so is not only unethical but crosses the lines of Medicare policy.
6. Understand that providing Connected Care is a Team Effort. Medicare has created Connected Care to be provided under general supervision. What does that mean? General Supervision means that a Qualified Provider must be the supervisor of a service that can be partially completed by internal staff that provide phone outreach/care coordination in a detailed time stamped/date stamped manner under strict CMS regulations. Often over-burdensome to office staff, care coordination services are often provided by a third-party contractor. Regardless of the manner of delivery, the process is about taking care of a Medicare patient in sympathetic manner to improve his/her healthcare journey.
7. Understand the importance of education. Marketing materials from banners to brochures to digital services to videos to mailers. It matters. Not just educating patients but educating staff. Remember, Connected Care is in the evolution that EHRs were several years ago.
8. Understand the goals of Connected Care—Connected Care was created to improve the health of the patient while preventing unnecessary ED visits and Hospitalizations. Connected Care has been a key success for Medicare policy and is evolving into new code sets on an annual basis. CMS initiatives advocate for finding ways to increase enrollment annually. Medicare saves money while providers gain well deserved revenue.