Implementation of chronic care management services in a patient-centered medical home

Service or Program:

Chronic Care Management (CCM) provided to patients with at least 2 chronic conditions became reimbursable by the Centers for Medicare and Medicaid Services (CMS) on January 1, 2015. Services must account for at least 20-minutes of non-face-to-face time, and may include care coordination, preventative care review, and self-management education including medications. Services can be conducted by "clinical staff" under general, rather than direct, supervision. CCM creates an opportunity to reconcile medications and reinforce adherence. At our geriatric patient-centered medical home (PCMH) in an urban academic medical center, a pharmacy team, serving as "clinical staff", initiated collaborative CCM services focused on medication use and adherence. We developed an electronic dashboard to aid in population management.

Justification/Documentation:

Quality management of complex chronic diseases requires ongoing medical care and communication, which must often be provided beyond the confines of a primary care visit. Medication and lifestyle adherence are associated with reduced chronic disease burden and decreased health care utilization. Pharmacists have expertise in influencing positive medication adherence.

Transferability:

Prior to billing for CCM, a patient must provide written consent for services. Additionally, a number of CMS directives determine patient eligibility for billing CCM in a given month. Using a dashboard in provision of services can assist in workflow, prioritizing patient care, and billing. In our PCMH, collaboration of interprofessional staff, including pharmacy residents and students, was key in implementing CCM services. Pharmacists practicing in primary care can adopt our model.

Impact:

We anticipate that provision of CCM services will lead to improvements in medication adherence, medication access, and chronic disease outcomes such as reduced A1c and blood pressure. We also anticipate increased vaccination rates and Medicare Annual Wellness visits, and a decrease in emergency department visits. Increased revenue as well as an increase in patients scheduled for in-office pharmacotherapy clinic visits is expected.