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Connecting to Chronic Care Management Services Partner Webinar


>>Female Speaker: Good
afternoon and thank you for joining the Connecting to
Chronic Care Management Services Partner Webinar. This webinar is hosted by
the Centers for Medicare and Medicaid Services, Office
of Minority Health. And the Federal Office of
Rural Health Policy at the Health Resources and
Services Administration. We have an exciting
agenda planned for today. During this webinar, we will
provide an overview of the newly launched Connected
Care: The Chronic Care Management Services Resource
initiative, designed to educate healthcare
professionals and consumers on the benefits of chronic
care management services. This webinar is intended
for national, regional, and local organizations,
interested in learning more about the Connected
Care initiative and CCM. It is not intended for the
press, and remarks are not considered on the record. If you are a member of the
press, you may listen in but please refrain from asking
questions during the Q&A portion of today’s call. If you do have inquires we
do want to hear from you. Please contact CMS at
[email protected] To go over a few logistics,
this webinar will include a question and answer segment. And we want your input. So, please participate,
it’s a discussion. Feel free to share questions
and comments in the chat window on the right
side of your screen. We also have access to a
real-time transcription of this event. And you can see
the bit.ly there. If you have any technical
issues please contact gotowebinar at 855-352-9002. And now it is my distinct
pleasure to welcome our speakers for today. Doctor Cara James, Director
of the CMS Office of Minority Health, and Mr.
Tom Morris, Associate Administrator for Rural
Health Policy at HRSA, will provide opening remarks
that help to show the significance of chronic care
in our country as well as the Chronic Care
Connected campaign. Michelle Oswald, Program
Manager within the CMS Office of Minority Health
will provide an overview of the Connected Care
initiative to present its purposes and resources. She will also explain how
organizations such as yours can partner to help promote
the benefits of CCM. We’ll also hear from some of
our partners, Karla Isely, and Lori Weber, from
Noridian Healthcare Solutions. Ann Stanberry from TMF,
Health Quality Institute. We may also hear from
another partner from the Albany Area Primary Health
Care, Clifton Bush. And we’ll be giving brief
presentations to share stories from the field and
resources that you may find beneficial for CCM. I will now turn the webinar
over to Doctor James.>>Cara James: Thank you,
Monique [phonetic sp]. And thank you all for
joining us here today on this exciting day as we’re
kicking off our Connected Care: The Chronic Care
Management Resource initiative. We at the office of Minority
Health here at CMS are very excited about this
opportunity, because as we work to ensure that all of
our CMS beneficiaries have achieved their highest level
of health and disparities are eliminated in access and
quality of care, focusing on chronic conditions and what
we can do to ensure chronic care management is an
important part of that. And as we’re going to talk
about the focus of today, we know that seven in ten of
the top causes of death are chronic diseases. And people with chronic
conditions account for more than 80 percent of our
national healthcare spending. When we look at our Medicare
population, we know that two-thirds of our Medicare
beneficiaries have two or more chronic conditions. Many of these individuals
disproportionately burdened are people of color and
those in rural communities. And it’s one of reasons why
today is such an important point as we are officially
kicking off our Connected Care campaign. As we want to educate
healthcare professionals and consumers about the benefits
of chronic care management for Medicare beneficiaries
living with two or more chronic conditions. And we’re excited in partnering
in this endeavor with our colleagues at the Federal Office
of Rural Health Policy at the Health Resources and
Services Administration. As we embark on this to help
our particularly vulnerable populations benefit from chronic
care management services. And I want to thank our
speakers for providing their on the ground perspective
and our partners about what they are doing to help
provide ideas for you about how you might embed some of
these resources and services into the communities and
populations that you work with. So, without further ado, I want
to turn it over to Tom Morris the Associate Administrator of
Rural Health Policy at the Health Resources and
Services Administration. And again, thank you all for
your participation today. Tom?>>Tom Morris: Thanks Cara,
I couldn’t agree more with your point and I really want
to thank you and your staff for the partnership
and this effort. We really are really
happy to be part of it. It’s my pleasure to be the
Director of the Federal Office of Rural Health Policy and
in that role, we’re charged with advising the Secretary
of the Department of Health and Human Services, on
healthcare issues and how they affect rural
communities. Including access to quality
healthcare, because many of the folks on this call
likely know rural communities face some real
challenges in terms of access to care. We know that rural areas
tend to have higher rates of chronic illness and poor
overall health when compared to urban residents. Folks from rural areas tend
to have fewer healthcare providers, it’s harder to
find clinicians to practice out there, and they often
have to travel a greater distance to get that care. I don’t think it’s any
surprise that these factors likely play a key role in
what we’re seeing as a growing disparity in life
expectancy for rural America compared to the
folks in urban areas. And that gap has grown
considerably in the past 20 years and appears to be
growing based on the most current data. So, I think whether we’re
talking about heart disease or lung cancer, or stroke,
it’s just a fact that rural residents face some real
challenges in terms of addressing those conditions. And that’s why we’re excited
about this campaign and the opportunity to work with the
CMS Office of Minority Health. Because I think we’re going
to have the opportunity to bring important attention
to this issue and hopefully turn some of these
metrics around. I believe that the Connected
Care campaign for Chronic Care Management is going to
be particularly relevant to rural communities. Because of what we know about
the demographics out there. And it will also be
important, not only for the patients, but also for the
providers who serve them. This implementation of
chronic care management services by physicians
and nurse practitioners, physician assistants, and
nurses, in rural areas working in these
communities, I think it has the potential to really not
only educate rural residents about things they can do to
better manage their care. But I think that it’s going
to also help rural providers take advantage of a
number of new tools. Some billing codes that
you’ll hear more about and other initiatives that CMS
has underway that I think are going to make a real
difference moving forward. So, we’re looking forward
to the next steps on this campaign and really
leveraging this on behalf of rural and under-served
communities. And so, with that, I’ll
turn it over to Michelle.>>Michelle Oswald: Great,
thank you so much, Tom. My name is Michelle Oswald, I’m with the CMS
Office of Minority Health. And I’m going to talk to you
today about chronic care management services and our
new Connected Care campaign. So, what is chronic
care management? Chronic care management is
defined as services provided by a physician or
non-physician practitioner, and their clinical staff,
per calendar month, for patients with multiple
chronic conditions expected to last at least 12 months
or until the death of the patient. Chronic care management is
person-centered and requires more centralized management
of patient needs and coordination among
practitioners and providers. In 2015, Medicare began
paying separately under the Medicare Physician Fee
Schedule, for chronic care management services
furnished to Medicare patients living with
multiple chronic conditions. CMS first established
payment for CPT code 99490, to pay providers for at
least 20 minutes of clinical staff time, directed by
a physician, or other qualified healthcare professional,
per calendar month. CMS has been working to make
rural changes that enable separate payment for more
complex and time-intensive chronic care
management services. As well as reduce
administrative burden by improving alignment with
coding language, simplifying the patient consent, and
reducing documentation rules. With that, in January 2017,
CMS added separate payment for three additional billing
codes in response to feedback from healthcare professionals
across the country. So, today, we won’t be going
into detail on chronic care management services and
requirements but there are fact sheets and frequently
asked questions available on the CMS Care Management
page at www.cms.gov. If you click on the search
engine and type in chronic care management, those
fact sheets will come up. You can also send your
technical questions to [email protected] or go to our
website, go.cms.gov/ccm to view our past webinars. Today, I’m excited to
talk to you about a new initiative that we are
launching around chronic care management called
Connected Care. Connected Care was developed
by the Centers for Medicare and Medicaid Services Office
of Minority Health in partnership with the Federal
Office of Rural Health Policy at the Health Resources
and Services Administration. It is a national public
education initiative that seeks to raise awareness of
the benefits of chronic care management services among
healthcare professionals and patients, particularly in
rural areas and among racial and ethnic minority
populations. The Connected Care campaign
has two primary audiences. The first are healthcare
professionals, particularly physicians, clinical
nurse specialists, nurse practitioners, certified
nurse midwives, and physician assistants. But also, ancillary
and support staff. This also includes Rural
Health Clinics, and Federally Qualified
Health Centers. The second audience
are consumers. Specifically, Medicare
beneficiaries as well as those who are dual eligible
for both Medicare and Medicaid with two or more
chronic health conditions. Through Connected Care, we
will place a special focus on reaching underserved
rural populations as well as racial and ethnic
minority populations. The Connected Care campaign
is a national initiative, so we are striving to reach
every state, but we will have a targeted
focus in four states. Using Medicare claims data,
CMS identified two markets within each of
those four states. One rural county
and one urban area. To implement localized campaigns
with the support of CMS, and HRSA regional offices, and
partners such as yourselves. Target markets were selected
on a variety of factors including Medicare enrolled
beneficiary data, existing use of chronic care
management, the prevalence of two or more chronic
conditions, as well as the adoption of electronic
health records. The campaign includes a mix
of outreach approaches, including paid and earned media,
social media, partnership development, and patient
and provider education. We have developed a
comprehensive information hub on the CMS OMH website
that provides links to our suite of chronic care
management materials available to download. The Connected campaign
Initiative is officially launching today and will run
through the end of July 2017. We will implement a variety
of different communication activities during each month
of the campaign and all of these activities will be
pulled together and support a report to Congress that’s
due in December 2017. We are very excited about the
enhancements that we’ve made recently to our connected care
website, go.cms.gov/ccm. Our goal is for this site
to be a one-stop shop for chronic care management with
all of our new products as well as links to chronic
care management resources. Including the existing CMS
Care Management page, CM fact sheets and FAQ’s, and
information on our upcoming CCM webinars and events. As part of the initiative,
we are offering some new resources for healthcare
professionals. One of those resources is a
web-based toolkit, that is now available to download
as a PDF, on our website. Some items included in the
toolkit include, guides to getting started with chronic
care management, and how to talk to you staff and
patients, materials that explain what chronic care
management is, who it’s for, why it’s beneficial, and how
to bill for those services. As well as links to other
resources, as well as examples of sample
CCM materials. We also have a testimonial video
that’s coming soon, which will have healthcare professionals
sharing their experience with implementing chronic
care management programs. Educational materials are
also available to share with patients, to include a
patient flyer and a poster, which we will talk
about on the next slide. We’ve created educational
materials that can be adapted for physician practices
and shared with your patients. We have in clinic posters
available to display in doctor’s offices, as well as
postcards that can be shared with patients, all
highlighting chronic care management benefits. We are also finalizing an
animated video for patients, that explains the benefits
of chronic care management services that doctors can
also play in their offices. Again, these materials are
all available to download at go.cms.gov/ccm and if you’re
interested in ordering materials you can e-mail
us at [email protected] Partnerships are very
important for this initiative, we encourage
organizations such as those of you on today’s call
that represent healthcare professionals, health
systems, rural clinics, community health centers,
patients, and organizations serving racial and ethnic
populations, as well as caregivers, to reach out to
us and get involved at the national, state, and
community levels. For our partners, we now
have a partner toolkit available on our website. This toolkit is also web
based and available on our website to
download as a PDF. The toolkit contains
suggested activities that we hope will be useful for all
types of groups to talk to healthcare professionals
and consumer audiences. It was designed to make your
job a little easier to get information out about
chronic care management. In the toolkit, we provide
suggested ideas on how you can spread the word, to
include, publishing a newsletter article, or a
blog post, or sending a blurb in a newsletter
or e-mail Listserv. We will also have social media
resources, such as sample Facebook posts, and tweets,
along with graphics coming soon. Each of these will be
offered in both English and Spanish so we can reach a
wider network of consumers and partners. Here, again, you can see
some of the ways that you can share the resources in
chronic care management information through your
existing communication channels. So, we hope that you will
join us in making this initiative a success.>>Cara James: Thank you
very much, Michelle. Now I would like to
introduce Karla Isley. She is the JF Project Manager
at Noridian Healthcare Solutions. Karla?>>Karla Isley:
Thank you so much. This is Karla Isley and
with Noridian Healthcare we appreciate the opportunity
to collaborate on the Connected Care: The Chronic
Care Management campaign. Noridian Healthcare
Solutions is the Medicare administrative contractor
for fee for services for traditional Medicare in
the state of Washington. One of the four pilot states
identified in Michelle’s earlier slides. We’re very excited to
support this campaign and we have resources on our
website that Lori Weber, our Provider Outreach
Education representative will briefly go
through at this point. Thank you, and I’ll
turn it over to Lori.>>Lori Weber: Well,
thank you, Karla. Now, I would like to let the
attendees know, as the MAC contractor, Noridian is
continuing our dedication to educating the
provider community. We have been presenting CCM
Webinars since the original implementation in 2015. And with the 2017 updates,
we just most recently had one last month in February. If you were not able to
attend that presentation we will have another one in
May, and we’ll have all the information posted in
the next week or so. This is all located in this
link shown here and what we’ll cover and what we
have been covering is a few slides on the CCM overview
and what services are involved; the highly
anticipated 2017 update that assists providers and adds
additional codes, that have already been discussed;
who is eligible, both the providers and Medicare
beneficiaries; what needs to be met for the provider
scope of service; how to bill and document properly;
and lastly, valuable resources and other generic
useful information. And then we should have our
website updated, as I just talked about. And providers will be able
to browse by topic for the CCM. Noridian is also finalizing
recordings under self-paced training and these will
consist of a three-part series. Provider education will
continue with quarterly webinars, so if you miss
that one in February; like I said, our next
one is in May. We will involve as many
medical and specialty associations to communicate
and promote CCM as well. Lastly, if you’re in a
Noridian state, please sign up for our Listserv, which
are bi-weekly e-mails to keep on the cutting edge
of these promotions and updates. And thank you.>>Cara James: Thank you
very much, Karla and Lori. I now want to introduce
Ann Stanberry. She is the Product Director
for Immunizations and Chronic Care for TMF,
Health Quality Institute. And she will share TMF’s
experience with recruiting and helping clinicians
implement CCM services within their practices. Ann?>>Ann Stanberry: Thank you
very much for inviting me to speak today. I’m Ann Stanberry and I’m with the TMF Health Quality Institute. We’re the QIN QIL and we
cover a five-state area, five-state/territory area,
and we’re under contract with CMS to provide quality
improvement services to all of the providers
that we work with. We work with a wide variety
of providers, hospitals, physicians, home health
agencies, long term acute, and other providers as well. The geographic area we cover
is Arkansas, Missouri, Oklahoma, Puerto
Rico, and Texas. In September, we received a
two-year contract from CMS for a special innovation project to
work with providers to actually implement chronic care
management services. And our goal has been to
recruit and work with at least 100 clinicians
in Arkansas, Oklahoma, Missouri, and Texas. I’m pleased to say right
now that, as of today, we have recruited at
least 100 clinicians and we’re still recruiting. And our job with them is to
provide one-on-one virtual and in-person technical
assistance to help them understand how to
implement CCM services. In addition, we’re providing
educational webinars, tools, and resources. We have a website as well. Next slide, please. So, how we’re helping
our recruited providers. As I said we’re doing
technical assistance, we’re helping our providers
identify their eligible Medicare fee for service
beneficiaries who may qualify for chronic care
management services. One of the big pieces of
what we’re doing is walking through with practices what
their work-flow processes are. To help them see how CCM can
fit into existing work flows or with slight modifications
to work flows that they can start using CCM services. We work with them on billing
requirements, identifying staff to deliver CCM, how to enroll
patients, how to use Telehealth. We’re doing regular
educational webinars on CCM and of course publicizing
all of the wonderful CMS webinars that are
being offered. We have provided a number
of tools for our providers, like patient letters, care
planning documents, contact tracking logs, and
implementation checklists. One of the things that
you’ll see on the next slide is a picture of our CCM website,
where we have our toolkits and resources and all of
our educational events posted. And so, you can see this
is what our chronic care management landing page is. It’s part of a larger
learning and action network that TMF offers that
includes all of our quality improvement projects. If we slip — no, go to
the next slide please. Anybody who’s interested is
free to have an account at our website, which
is, www.tmfqin.org. Once you have registered
you’ll be promoted to join the networks that you’re
interested in and we invite anybody that’s interested
to join our chronic care management website. And this is our contact
information if anybody is in our geographic area, which
is Arkansas, Missouri, Oklahoma, and Texas, we
would love to hear from you and help you in
any way possible. Thank you very much.>>Monique LaRoque: Thank
you very much, Ann. And now I want to turn
it over to Clifton Bush. He is the Chief Operating
Officer for Albany Area Primary Health Care. And he’ll share what his
organization is doing to support CCM in his
brief statement. Clifton?>>Clifton Bush: Thank you. Good afternoon,
how is everyone? Can you hear me?>>Cara James: Yes,
thank you, Clifton.>>Clifton Bush: Hello,
I’m Clifton — thanks. I’m Clifton Bush from, again,
Albany Area Primary Health Care. And just to give you a
little bit of background about our organization, we
are a Federally Qualified Health Center located
in southwest Georgia. We cover about seven
counties and we have different disciplines
within our organization. Such as primary care, OBGYN,
dental, podiatry, we have a HIV program, as well as
school-based health centers. So, we have 25 clinical
sites with 27 actual buildings within
our organization. And so, just to get to the
chronic care management, what our organization —
how we started chronic care management is that we
actually started with a nurse practitioner that —
she actually had got sick and couldn’t work as much
in the clinic anymore. And so, it was the ideal
time when chronic care management had come out for
Federally Qualified Health Centers, that we
started with her. And so, she would actually
see patients in the clinic and then she would help
along with the nursing staff and the support staff within
the clinic as far as you know introducing chronic
care management to the patients with different
fliers that we utilized for marketing and also just
you know by word of mouth, informing the patients
about the program. And so, she would get them
signed up and make sure that they had the annual exam
that the patients needed. We work with eClinicalWorks,
which is our electronic health record system. And appropriate individuals
within our organization — which included me and our
insurance manager, and the nurse practitioner that was
helping to get this going — got together and looked at
the chronic care management module that was inside of
our electronic health record and practice
management system. And so, this module that was
in our EHR system actually helped the nurse
practitioner with time, the appropriate amount of
minutes that you know she talked to the patients, and
actually would send the information to the insurance
company through the clearing house for the bills, you
know, the claims to go out the insurance company. And so, we liked that module
that the EHR system already had. So, we worked with
eClinicalWorks in order to implement that module within
our organization for the nurse practitioner to be
able to do the chronic care management with the patient
and actually send you know send the claims with the
appropriate code off to the insurance company. And so, our electronic —
eClinicalWorks also had different again marketing
tools that we could use. They already had, like,
a consent form, a sample consent form that was
approved to use for clinic care management. And so, we kind of tweaked
the consent form and used some of their marketing
that they had. And, you know, tweaked that
to fit our organization. One of the things that we
did find out when we got started with the chronic
care management within our organization, is just making
sure to notify patients about if, you know, they may
have a co-pay from some of the, you know, like,
advantage plans, et cetera. But the patients
enjoyed it very much. The patients actually liked
afterward that a nurse practitioner was contacting
them to follow up on, you know, asking them about
their medications, all the education that she was
giving them, you know, from their visit. And just making sure that
they’re doing well, et cetera. And so, we had a lot of
patients that, you know, would talk about how much
they enjoyed the program. And so, currently, we will
be looking at spreading this program to other clinics
within our organization. But that’s the gist of how
we started chronic care management and kind of
what we’re doing now. And, you know, and the
enjoyment of the patients on the program. Any questions?>>Female Speaker:
Thank you, Clifton. We do have one question. “How did you overcome any
barriers to the informed consent process? What was successful
in your community?”>>Clifton Bush: So, I think
what was successful is that the nurse practitioner
because she was actually the one that would be doing it
and she would see some of the patients for their
visits within the clinic. And talking to the patients
about, you know, you have to sign this consent form et cetera, in order to participate
in the program. And just educating the
patients about the program. And also, she informed them
that she would be the one that would be
doing the program. I think with her, you know,
with the patients knowing her within that community
helped a lot with us.>>Female Speaker: Another
question for you Clifton. In terms of the co-pay, how
did you handle that, and were you able to identify
those who had SSI to be able to support that co-pay?>>Clifton Bush: Yes. That’s something we worked
with our insurance. We have a good number of
insurance clerks within our organization and our
dedicated to certain you know payers and clinics. And so, they helped us to
identify those patients. As I stated before, we did
have some push back from a couple of patients. Because of the co-pay. And that’s when we found
out, you know, when we came back to the table that’s
something we really need to explain to the patients. If, you know, they have a
co-pay and so, that’s one thing. Make sure whoever is
introducing the chronic care Management Program to the
patient that they explain to them they will
have a co-pay. Because we did have some
patients that did, you know, say they didn’t want to
do the program anymore. The majority of them did
stay with the program. But there were a couple that
did not want to participate because of the co-pay issue. And so, I think by us
explaining it upfront from the point where we knew that
we needed to do that, it helped a lot to make sure that
the patients understand that. So, they could say, “I do
want to participate,” or, “No I don’t want to
participate within the program.”>>Female Speaker:
Thank you, Clifton. This question is for
Noridian and TMF. “Do you provide support
if someone has questions regarding a specific
reimbursement approach? And can you please share the
kind of technical assistance that you will help
provide us with?”>>Ann Stanberry: This is
Ann with TMF, and we have at times we have answered questions
about — billing questions. If we’re uncertain about how to
respond we call the MAC on behalf of providers to try and
get some additional information. Because we’re certainly not
the final billing person, we don’t want to give
inaccurate information. And as for technical
assistance that we provide to the providers that we’ve
recruited, we actually work with them from the
beginning of the process. So, [inaudible] who their
patients are, to help, you know, how to reach out to
those patients to recruit them and to try it on
with staff within their practices, who are going
to be providing the CCM services, what type of CCM
services, and how often they’re going to be
providing those to the patient. And then, helping them with
EHR documentation and any billing issues that
they might have.>>Lori Weber: And this is
Lori from Noridian Education. And we will do our best
as well to answer those questions about
the details of CCM. For the technical pieces,
you may have to go to your vendors and make sure that
that’s all set up or your clearing houses. And I might defer to CMS
to continue with that. But we’ll do everything in
our power to help with the coding, the billing, the
documentation, everything that we can help with
for our Noridian states.>>Female Speaker:
Thank you both. I also have another
question for Clifton. Can you share how many
patients, around about you’ve been able to
enroll in Albany? As well as any other best
practices for other people who are helping people
on the front lines?>>Clifton Bush: So, I think
currently we have about 80-100 patients may be
enrolled into the program. And so, I would just say
the best practice that we learned is just to make sure
if you have the opportunity to make sure to educate your
support staff, the nursing staff, within the clinics,
or whoever is going to be you know talking to the patients
before introducing the program. And just making sure that
they are aware of the different things within the
program, especially anything, you know, for
example, like the co-pays that could be a barrier to them
participating in the program. But I would just say
the education piece. Just make sure that
patients are educated.>>Female Speaker:
Thank you, Clifton. The next question
is for Michelle. Michelle, are CCM services
available in Federally Qualified Health Centers
and Rural Health Clinics?>>Michelle Oswald:
Thanks, Monique. So, yes, actually as of
January 2016, Rural Health Clinics and Federally
Qualified Health Centers have been able to bill for
chronic care management services for the one
particular code, 99490. I will say to keep an eye
out for any essential changes or updates to the
physician’s fee schedule proposed oral changes that
may be out late spring.>>Female Speaker: The next
question is also for Michelle. “Are you beta testing the campaign in the four states mentioned? If so, when will it be
rolled out nationally, can you please clarify?”>>Michelle Oswald: Sure. So, as I mentioned Connected
Care is a national campaign. We are hoping to hit every
state with information. But we are specifically
targeting the four states that I mentioned, Georgia,
New Mexico, Washington state, and Pennsylvania with
more targeted outreach efforts.>>Female Speaker: Thank
you very much, Michelle. And if someone wants to
become a partner in this campaign, what
should they do?>>Michelle Oswald: If
someone wants to become a partner, they can e-mail our
CCM mailbox at [email protected] And also, check out our
materials on our website particularly our partnership
toolkit, which has all the materials available to
be able to support the campaign.>>Female Speaker:
Thank you, Michelle. I know that we’re not going
to go into many specific questions about
billing at this time. However, that e-mail that
she shared if you do have any questions you can send
it to them, to that e-mail. As well as you can contact
AMAX who are on the frontlines to
help providers. So, for CCM, there is one
basic question regarding whether healthcare practices
need to reconsent the patient now that we have
the new codes, if they’ve already consented
to that service?>>Michelle Oswald: No. So, once you’ve received
patient consent, if that was done — well, if it was the
written consent last year, or if it’s your oral
consent, verbally this year, you do not need to
reconsent that patient.>>Female Speaker: So, if a
clinic would like to order materials to be sent to
their area, I’m getting a question for example from
Minnesota, what should they do?>>Michelle Oswald: You can
e-mail the CCM mailbox at [email protected] Please provide your name
and mailing address and specifically how many of
each material that you would like to order.>>Female Speaker: We are
getting some questions about helping to support informed
consent as well as what would be included in
the care plan. I did want to highlight
that we do have on the CCM website a sample healthcare
professional toolkit, which answers many frequently
asked questions. It has some of the tips to
help you prepare a patient to understand what are
the benefits of CCM. It also has one of
the key elements of a chronic care plan. It is not prescriptive it
is just some of the key elements that you may
want to consider in your comprehensive care plan. That HCP toolkit is
available on our website. And we do appreciate and
acknowledge the questions to support that. We want to encourage
you to go there. Also, we have a patient
education postcard that you can have in your clinics. You’re are able to print
that out and share it. Also, to leverage it
in your community. In addition, we have some
posters if you’re interested in prompting your patients
to ask for this service. That poster can be
downloaded and printed. We also have some copies
available here at CMS. So, if you’re interested
in that please go to our website or you can
send us an e-mail. This question
is for Michelle. “What are the projected
outcomes for this campaign? What does success
look like?”>>Michelle Oswald: So,
success for us, what we would hope to do is be able
to reach every state across the nation with materials. We also, although we’re
not going to relate any particular uptake in chronic
care management services, we will be evaluating the
initiative and looking at Medicare claims data for the
next six months and beyond particularly to see if
there’s an increase in the use of chronic care
management services throughout the country.>>Female Speaker:
Thank you, Michelle. Clifton, we have a couple
of questions for you. “How is the care coordinator
being notified by the hospital? How do manage that check-in
with the patient so that you can help to connect care
and support the transition between a hospital and home and
then back to your clinic? What does that look like
for you in your community?” Okay, Clifton
may be on mute. But I did want to share that
the monthly check-ins are meant to provide an
opportunity to call on the patient to see how they’re
doing on their medications, to check-in on their health,
as well to see if they visited any other healthcare
facilities, ambulatory care, emergency care. We are aware that in some
communities there is a link between hospital and
ambulatory care and the actual practice. And in some
places, that’s not. But at least that monthly
check-in is an opportunity to follow up on what has
transpired since the patient’s last visit. This question is for
TMF and Noridian. “Can you discuss a bit more
about the webinars that you’re going to be hosting
and the kinds of technical information you’ll be able
to share with clinicians?”>>Lori Weber: Hello,
this is Lori Weber again from Provider Education. And the one that we’ll be
providing in May, I’m not real sure what you mean by
“technical information” as far as we’re not going to
get into each different practice management system or
electronic health records. But what we will do is give
you all of the notifications and requirements that
came out from CMS. Some of them have been
relaxed, which we’re really happy to hear about. And those, what we could do
is if you’re in an Noridian state I would be happy
to send you a previous presentation if you
wanted to e-mail me. And I don’t know if I should
be giving my e-mail out to the whole country now, or
if that person can you tell what state they’re in?>>Female Speaker: We
can forward it to you. Thank you.>>Lori Weber:
Excellent, thank you. I look forward
to helping them.>>Ann Stanberry: This is
Ann Stanberry from TMF. And we’re having quarterly
education Webinars. Those are all posted
on our website. And we deal with things like
the CCM billing codes, the scope of CCM services, we’re
going to be talking about ways to handle patients with
multiple chronic conditions and care coordination
services in general in upcoming webinars because
we thought that would be helpful to providers. And any of the resources
and tools and technical assistance that we offer
is posted on the website. And anybody who’s interested
can join our website and look for those
tools and resources. For this particular person,
if you have further questions my contact
information is in the presentation so feel
free to give me a call. And we’ll see if we can
help you more specifically.>>Female Speaker:
Thank you both. The next question is about
the languages that the materials will
be available in. Michelle, can you let us
know if it will be in any other language
besides English?>>Michelle Oswald: Sure. So, at this point several
of our materials that are provided in the toolkits
will be available in Spanish. Particularly, the healthcare
professional information card as well as the consumer
cards will be available in Spanish. And then, we’ll also be
targeting some Spanish populations in particular
states that we’ll be in. And we’ll have some really
specific social media information and some of the
Listserv announcements and other basic information in
the toolkits will also be translated in Spanish.>>Female Speaker: And,
Michelle, several people are interested in
that e-mail again. Can you please repeat?>>Michelle Oswald: Sure. It’s ccm — for chronic care
management — @cms.hhs.gov.>>Female Speaker:
Thank you Michelle. We also got a request to go
back to our slide on the CCM specific code. So, we’re leaving this up
here for a few seconds for you to take a look at. We’ve also gotten questions
about whether this presentation will be
available online. We have posted it actually
right now you can download it from this webchat. If you look in the right box there
is a tab called handouts. And if you click on that,
you’re able to actually download this presentation. In addition, we’ll be making
this audio available on our website and you can access
that and download it. We’ll send an e-mail to
you when it’s all posted. We’ll do a quick scan for
any additional questions. If there’s anything that you
would like to ask please let us know. The next question is, “Are
folks in Puerto Rico able to participate in CCM as
well as the campaign?”>>Michelle Oswald:
Thanks, Monique. So, yes. If you’re in Puerto Rico you
can participate in bill for chronic care management
services in Puerto Rico. If you have particular questions
I know that our New York regional office supports the
folks in Puerto Rico. And if you want to follow
up through e-mail we can connect you there. And that’s [email protected]>>Female Speaker:
Thank you, Michelle. The next question is, “Is
there a cost to order materials from CMS or
even to download them?”>>Michelle Oswald: So, the
materials are available at no cost. You can download the
toolkits that are online as well as those products,
they’re available by PDF. And you can also order hard
copies again through the CCM mailbox and those are
available at no cost to you. Just provide your mailing
address, as well as how many of each product that you
would like to order.>>Female Speaker:
Thank you very much. We’ve gotten a couple of
questions, again, about downloading resources
and e-mailing CMS. We are going to move again
to that slide so that you have a chance to
take a look at this. Again, if you go to our
website go.cms.gov/ccm, that site will have all of these
resources that we’re talking about today. And we’re going to
continue adding to those. Also, if there’s something
that you’re feeling like you need in your community that
we currently don’t have, please send us an e-mail
to [email protected] So, Michelle, we’re getting
some questions about what does it mean to
be a partner? What kinds of activities are
you asking people to get involved in?>>Michelle Oswald:
Thanks, Monique. So, some of the activities
are included in the partner toolkit that’s
on our website. Those activities could be
as simple as sharing the information with the folks
that you work with within your communities. Whether it’s a healthcare
professional or whether you work with Medicare
beneficiaries one-on-one, share the information that
we have about chronic care management services. We can also use some
assistance in — if you’re interested, in presenting
at any of the local states. If you’re interested, we’ll
have a slide deck available with talking points that you
can incorporate into your information if you’re going
to be at a conference, or if you’re going to be
presenting to folks, you can take and use as many of those
to incorporate as you need. And then, just share with us
the stories that you have if you’re having some issues
within your region or if you’re talking with Medicare
beneficiaries and they bring up some concerns,
please share. Also, I like to hear
success stories. So, share them all in our
mailbox [email protected]>>Female Speaker: We’re
seeing a lot of engagement and interest from
various states. We do want to repeat a note that
this is a national campaign. We welcome participation from
every state in this country. It would be fantastic if
you all can get involved. We’d also love to hear
about what you’re doing. So, please send us an e-mail
and let us know if you are planning to share any
materials and resources in your state and
your community. Again, those materials
are available for a free download and there’s
not a cost to you. You can also e-mail us if
you’d like to access them. With that said, I would
like to thank everyone for participating
in this webinar. We know that you may have
some questions after this meeting, so please contact
us and we want to hear from you. We also value your
feedback and input. After the conclusion of this
webinar you’re going to get a very, very, brief
questionnaire to share some insights on how this is
working for you and what you need to help support
CCM in your community. Please take a few minutes to
fill those questions out, and, again, we are always
available to connect with you. Please feel free to
e-mail us at any time. Thank for your time today.

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