Medicare has implemented three programs to improve management of individuals with chronic conditions: Medicare Annual Wellness Visit, Transitional Care Management Reimbursement, and Chronic Care Management (CCM) Payment. The CCM Payment improves physician reimbursement related to the care of individuals with complex chronic conditions. The fee expands this strategy to all primary care practices serving Medicare beneficiaries and represents a critical step forward in recognizing that the essential features of primary care — continuity, whole-person focus, comprehensiveness, serving as patients’ first contact for new health issues, and coordination — are not optimally supported by the fee-for-service model.
Compiled by Amanda Griffith, Contributing Writer
Wake Forest Baptist Medical Center is leveraging functional status assessments and social determinants of health to advance its population health management efforts.
![]()
Medicare has implemented three programs to improve management of individuals with chronic conditions: Medicare Annual Wellness Visit, Transitional Care Management Reimbursement, and Chronic Care Management (CCM) Payment. The CCM Payment improves physician reimbursement related to the care of individuals with complex chronic conditions. The fee expands this strategy to all primary care practices serving Medicare beneficiaries and represents a critical step forward in recognizing that the essential features of primary care — continuity, whole-person focus, comprehensiveness, serving as patients’ first contact for new health issues, and coordination — are not optimally supported by the fee-for-service model.
In parallel, penalties for hospital readmissions and the move toward accountable care organizations have helped foster attempts to address elements of patients’ lives and behavior that influence the risk of disease and the effectiveness of medical treatment. Pamela Duncan, Professor of Neurology and Senior Policy Advisor for Innovations and Transitional Outcomes for Wake Forest Baptist Medical Center, describes how her organization furthers its population health efforts to manage individuals with complex chronic conditions by translating assessments of functional status and social determinants of health to generate actionable electronic care plans.
Q: What was Wake Forest Baptist hoping to accomplish by incorporating a chronic care management screener?
![]()
A: As the New England Journal of Medicine pointed out in a February 15, 2015 article, reimbursement policies that reward population health management and value-based purchasing have encouraged healthcare organizations to pay greater attention to modifiable determinants of health. As a result, what we have in the current healthcare environment is the growing importance of managing populations of patients and understanding what’s driving their engagement, health outcomes, and healthcare utilization.
Healthcare organizations have responded by focusing on capturing patient data and using analytics tools to formulate personalized plans for chronic care management patients. Last year, the Institute of Medicine (IOM) issued two reports based on the premises that healthcare providers and health systems can more effectively influence patient and population health if they have information on social and behavioral determinants of health. IOM suggested that EHRs capture sociodemographic, psychological, and behavioral factors, plus individual-level social relationships and community-level data.
To this end, we developed patient-reported measures (Duncan Functional Assessment for Personalized Care and Post Stroke Functional Assessment for Personalized Care) that help to systematically address our needs to meet population health initiatives while helping inform patients and providers about a patient’s capacity to self-manage his/ her own health and medications. In other words, we engage patients in the assessments, ask about their goals of care, and immediately develop recommendations for care. Patients are fed up with going into the healthcare system and feeling like the nurse or the doctor is looking at their computer and completing a checklist of questions, which leaves them wondering, “Why I am asked so many questions?”
Q: You selected Tonic as your partner. How does their solution work?
A: We partnered with Tonic Health to provide an iPad- and webbased patient data collection platform for personalized care. The technology suggests referrals for services based on the patient’s functional status, social determinants of health, and preferences. This platform quickly obtains this information at hospital discharge, in the clinic, or even in the home prior to coming to the clinic. The iPad technology, which includes a survey builder, allows me to change and customize questions in seconds and develop algorithms for clinical decision-making and referrals based on patient responses.
Q: What did you learn about your PHM efforts, and how did you react?
A: By working with nurse practitioners in post-acute functional assessments, we’re constantly evaluating patient information so it can be generated and interpreted in real-time. Population health should not just be about looking at data retrospectively and trying to predict outcomes. It’s about the need for real-time actionable care for the present and putting efforts in place to impact future healthcare utilization. It’s very important that when we consider population health management, we don’t just look at risk or healthcare utilization but also provide the right care at the right time. We don’t want to collect just any information — it needs to be actionable and personalized for each patient.
With our current platform we can see, for example, if a patient is prone to falling or has fallen multiple times and has injured herself in the past. With this platform, we will receive an immediate flag if a patient is a fall-risk and can then recommend that the patient receive a comprehensive fall assessment and outpatient therapy for management of that condition.
Q: How has Wake Forest Baptist benefited, particularly with regard to readmissions?
A: We’ve only just begun our efforts but are hopeful, particularly with a $14 million federal grant we received through the Affordable Care Act. The money will fund a statewide study of population-based stroke care that’s being led by clinicians and researchers right here at Wake Forest Baptist Medical Center.
The grant comes from the Patient-Centered Outcomes Research Institute and will focus on determining whether early supported discharge care up to 90 days after a stroke by a nurse practitioner and a post-acute nurse coordinator improves daily functioning and quality of life and reduces hospital admissions over a year. The study is also designed to measure the stress experienced by those caring for someone who has suffered a stroke and methods to reduce this stress. Each patient will receive an individualized care plan, informed by the results of the patient-reported assessments and the NP medical evaluation. These care plans will be provided to the primary care team and all post-acute rehabilitation providers electronically. They will also be available to patients. We expect the study to include at least 9,000 patients when it begins next year.
Q: What would you tell providers considering implemeting chronic care management screening for enhanced PHM?
A: We’re supposed to care for the sick patients in front of us and ask many questions in a 10- to 15-minute primary care patient visit. A lot, unfortunately, falls through the cracks, so it’s important to have a solution that can demonstrate benefits and utility to both patients and providers. Success depends on engaging frontline providers, something they’re not used to. Once they get it, they love it, but there have to be learning opportunities that show platforms like this won’t replace their clinical decision making but rather will support their efforts to provide each patient the best holistic care.
Q: In what ways do you plan on leveraging this technology in the future?
A: We think the wave of the future is to be able to ask the patient or caregiver, “What’s driving your challenges, your functional status, and your health?” We want to incorporate all of this information as part of an e-care plan and then provide educational modules immediately. For example, if a patient’s blood pressure is not within range, she or he would receive a brief educational message about why blood pressure management is so important and what they can do it about it based on their specific functional status, financial abilities, and health literacy levels.
In addition, we’re working with Elsevier, who has partnered with Tonic to help providers directly target the personalized needs of the patients. It’s all about getting the right education, on the right device, to the right patients — all in real time. The ultimate goal is comprehensive assessments and patient engagement to drive their care needs. If a patient is on multiple medications and is not sure why they are taking those medications or cannot afford them, we want to know that. Sometimes it’s the obvious questions that aren’t being asked.
Medicare has implemented three programs to improve management of individuals with chronic conditions: Medicare Annual Wellness Visit, Transitional Care Management Reimbursement, and Chronic Care Management (CCM) Payment. The CCM Payment improves physician reimbursement related to the care of individuals with complex chronic conditions. The fee expands this strategy to all primary care practices serving Medicare beneficiaries and represents a critical step forward in recognizing that the essential features of primary care — continuity, whole-person focus, comprehensiveness, serving as patients’ first contact for new health issues, and coordination — are not optimally supported by the fee-for-service model.
A: As the New England Journal of Medicine pointed out in a February 15, 2015 article, reimbursement policies that reward population health management and value-based purchasing have encouraged healthcare organizations to pay greater attention to modifiable determinants of health. As a result, what we have in the current healthcare environment is the growing importance of managing populations of patients and understanding what’s driving their engagement, health outcomes, and healthcare utilization.
