Transforming chronic care management with patient reported measures and timely data capture

Pamela Duncan
Pamela Duncan, Ph.D., Professor of Neurology and Senior Policy Advisor for Transitional Outcomes, Wake Forest Baptist Medical Center

Chronic care management is a serious healthcare challenge. Two out of three Medicare beneficiaries have multiple chronic conditions, according to the Centers for Medicare & Medicaid Services (CMS). Furthermore, CMS reports that over one half of Medicare beneficiaries less than 65 years old, sixty-three percent of those 65-74 years old, 78 percent of those 75-85 years old, and 83 percent of beneficiaries 85 years or older have two of more chronic conditions. Seniors with four or more conditions account for 37 percent of all beneficiaries, but close to three-quarters of total Medicare spending. Managing these multiple conditions becomes increasingly difficult without the proper tools, reporting mechanisms and engagement from patients.

The rising influx of Baby Boomers will have a staggering financial impact on the Medicare system, as well. Through 2022, “the aging of the population will cause spending on the major health care programs and Social Security to rise significantly,” according to the Congressional Budget Office (CBO). “In fact, during that period, almost all of the projected growth in such spending as a share of GDP is effectively the result of aging.”

Patients with multiple chronic conditions often have functional challenges (e.g., physical, cognitive and social) that limit their abilities to manage their health conditions and coordinate their care. Yet, the patient’s functional status is often an overlooked variable in healthcare management and utilization, especially readmissions (Journal of Hospital Medicine, doi: 10.1002/jhm.2170). Additionally, healthcare systems continue to treat patients on a disease-by-disease basis, and patients interact with a variety of specialists. In the United States, patients with two or more chronic conditions visit as many as 16 different providers in one year: the average Medicare patient had billable encounters with two primary care providers and five specialists per year. The result is unwieldy care management as patients struggle to manage medication interactions and their multiple health conditions with limited cohesion among providers and across the continuum of care.

Toward assessment of functional status for individualization of care

To meet the urgent needs of obtaining patient functional status and patient preferences, we have developed patient reported measures encompassing several functional domains (physical, cognitive, emotional and social). Within the measurement tools, patients also select their preferences for self-management, post- acute care and advance directives. Three patient reported measures have been created for immediate deployment in clinical practice.  

The first of the three tools is the Duncan Functional Assessment for Personalized Care, which may be implemented to support ambulatory practice for chronic care management. The instrument meets the Medicare chronic care management requirements that physical, mental, cognitive, psychosocial function and environmental assessment be performed to develop individualized care plans that are available electronically. The Post-Acute Stroke Assessment for Personalized Care was developed specifically for the assessment of patients post-stroke and is being utilized in the post- acute stroke clinic setting.  It includes the functional assessments required for Medicare reimbursement for transitional care management and ongoing chronic care management.

A Surgical Pre-Screen for Optimal Personalized Care is being implemented in the Wake surgical navigation programs to promote better pre-operative assessment of functional, social and medication management issues that impact post-surgical functional health recovery with the objective that these findings can be used to foster planning and coordination of post-acute services. The specific goals of this pre surgical assessment are to decrease post-surgical length of stay, ensure transportation at discharge, decrease post- surgery adverse events (readmissions, falls and medication errors), and decrease costly delays on the day of surgery. 

All three measurement tools may be implemented into real-time clinical practice at the point of medical decision making. The ultimate purpose of the measures is to have adequate assessment and documentation to guide medical decision-making and to implement care consistent with the patient’s functional needs and preferences for care. Just as patients’ genetic code may customize clinical interventions, systematically assessing functional status, social determinants of health and patient preferences may allow us to specifically tailor comprehensive care to improve healthcare quality and outcomes (Meyer,et al: Determinants of Health After Hospital Discharge; BMC Health Sciences Research 2014; 14:10).

Wake1Wake Forest Baptist Medical Center has partnered with Tonic Health to provide an iPad- and web-based patient data collection platform for personalized care and referrals for services based on the patient’s functional status and preferences. This new technology provides a platform to quickly obtain functional status and patient preferences at hospital discharge, in the clinic, or even in the home prior to coming to the clinic.

The patient reported assessments are collected via an iPad and/or web-based interactive system. The responses from the electronic assessment are available in real-time to generate recommendations for care as well as clinical alerts. These methods can produce immediate feedback to patients via PDF, text, or email, and generate summative reports to guide clinical decisions, automate referrals for services, and link patients and providers to health education.  Summaries and/or discrete data can be integrated with the electronic health record. And furthermore, the captured data can be analyzed to risk-adjust the population and to develop a functionally based predictive measure for hospital readmissions.

The innovative application of the Patient Reported Assessments within the Tonic digital platform is a timely strategy for hospitals, health systems and medical groups. Medicare has implemented three programs to manage chronic conditions: Medicare Annual Wellness Visit, Transitional Care Management Reimbursement, and Chronic Care Management Payment. The Medicare Chronic Care Management payment code, introduced in January 2015, improves physician reimbursement to manage individuals with complex chronic conditions. For example, physicians can bill $42 per patient, per month for 20 minutes of non-face-to-face care of Medicare patients with two or more chronic conditions.

The purpose of these programs are to develop plans of care for chronic conditions inclusive of physical, mental, cognitive, psychosocial, functional and environmental assessment. The assessment results support the creation of an electronic care plan, can be connected with an inventory of available resources, and ensure the provision of care congruent with patient’s choices and values. The ultimate goal of these programs is to develop individualized and coordinated care plans for better health management of individuals with multiple chronic conditions and with multiple providers.

Unfortunately, the requirements for payment under the new schemes are complex. They call on clinicians to rely on technologies to capture the cognitive, functional and environmental patient information required for individualized care plans. In order to facilitate the creation of patient care plans, the Tonic platform offers innovative technology to support primary care providers as they implement services such as the Medicare Chronic Care payment code. The Tonic iPad capture of patient reported function leverages the combination of engaging patients and using contextually relevant graphics, which range from birthday cakes to smiley faces. This patient-centric model allows clinicians to pursue more relaxed, engaging conversations with patients, as they elicit and share information with patients. The result: better clinician and patient engagement can improve patient–provider communication and increase patient satisfaction.

Finally, Elsevier, the largest provider of clinical and patient education materials, will partner with the Wake Post-Acute Stroke Clinics to select educational materials consistent with the patient’s functional status and preferences for care. Beneficial for both patients and clinicians, patients and their family members learn about the patient’s condition, as well as what they need to do to engage in their own care and why.  As a result, patients are more likely to perceive life-long care engagement that is vital and worthwhile. Elsevier already has a relationship with Tonic Health.

In summary, Wake programs are leveraging innovative patient measurement instruments in combination with digital solutions to capture comprehensive patient assessment data, formulating this data into a care plan, automating resource and education linkage, and applying this data to better coordinate complex chronic care across the health system. Wake’s first steps in this strategy include three key use cases: Pre-surgical screening, Chronic Care Management in the ambulatory setting, and Post-acute stroke follow-up. Next steps included data analysis for risk adjustment and predictive modeling in order to promote efficient allocation of health system resources.

Chronic Care Management Payment, Duncan Functional Assessment for Personalized Care, Elsevier, iPad, Medicare Annual Wellness Visit, Medicare Chronic Care Management payment code, Patient Reported Assessments, Post-Acute Stroke Assessment for Personalized Care, Surgical Pre-Screen for Optimal Personalized Care, Tonic Health, Transitional Care Management Reimbursement, Wake Forest Baptist Medical Center


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