Chronic Care Management Services Research Articles

Use of chronic care management service among Medicare beneficiaries in 2015-2019.

The Centers for Medicare and Medicaid Services (CMS) introduced chronic care management (CCM) services in 2015 for patients with multiple chronic diseases. Few studies examine the utilization of CCM services by geographic region, sociodemographic, and clinical characteristics. We used 2014-2019 Medicare claims data from a 5% random sample of fee-for-service beneficiaries aged 65 years or over. We included beneficiaries potentially eligible for CCM services because they had multiple chronic conditions (1,073,729 in 2015 and 1,130,523 in 2019). We calculated the proportion of potentially eligible beneficiaries receiving CCM service each year for the total population and by geographic region, sociodemographic, and clinical characteristics. The proportion of beneficiaries with two or more chronic conditions receiving CCM services increased from 1.1% in 2015 to 3.4% in 2019. The increase in CCM use was higher in the southern region, among dually eligible beneficiaries and beneficiaries with a greater burden of chronic conditions (2-5 conditions vs ≥10 conditions: 0.7% vs 2.0% in 2015; 2.1% vs 7.0% in 2019) and frailty (robust vs severely frail: 0.6% vs 3.3% in 2015; 1.9% vs 9.4% in 2019). Nearly one out of five recipients did not continue CCM service after the initial service. We found that CCM service is being used by a very small fraction of eligible patients. Barriers and facilitators to more effective CCM adoption should be identified and incorporated into strategies that encourage more widespread use of this Medicare benefit.

How Partnering with a Chronic Care Management Partner Improves Patient Communication and Coordination for Eligible Medicare Beneficiaries

The article discusses chronic care management services that are essential for patients with two or more chronic conditions. CMS has designed a care plan that facilitates communication and follow-up according to the chronic care management codes. The main goals of CCM services are to improve patient experience and satisfaction, patient outcomes, and provider and healthcare worker experiences, and to lower the total cost of care. Chronic care management services make it easier for patients to manage their chronic illnesses, improve communication between patients and providers, and ensure that providers understand their patients’ needs.

Pharmacist certification of drug therapy modification: A survey of pharmacist‐reported practices, facilitators, and barriers in Georgia

AbstractIntroductionCollaborative drug therapy management (CDTM) allows pharmacists to assess patients, administer medications, manage and adjust medication regimens, and order laboratory tests within a defined protocol. Pharmacist CDTM may aid in preventative care and chronic condition management.ObjectivesThe primary objectives were to identify CDTM services provided by pharmacists in the state of Georgia, examine factors associated with the provision of CDTM services, and identify barriers and facilitators to CDTM service provision. The secondary objective was to assess differences in CDTM practice between pharmacists who completed a Registered Pharmacist (R.Ph.)/Doctor of Pharmacy (Pharm.D.), postgraduate year one (PGY1), or postgraduate year two (PGY2) residency.MethodsUsing the Dilman method, this cross‐sectional study invited all 134 CDTM‐licensed pharmacists in Georgia to complete a 30‐min electronic survey. Data included demographics, training, services offered, disease states managed, and perceptions regarding CDTM implementation. Descriptive statistics, Welchs analysis of variance (ANOVA), and chi‐square were conducted using SPSS v28.ResultsA total of 36 (26.9%) pharmacists completed the survey. Participants offered a median of three CDTM services. A majority offered medication therapy management (86.1%) and chronic care management (66.7%). A majority offered services for diabetes (58.3%), hyperlipidemia (55.6%), and hypertension (55.6%). There were differences in the mean ranked number of CDTM services offered between R.Ph./Pharm.D. and PGY2 groups (−11.667, p = 0.019), and the mean ranked number of disease states covered between R.Ph./Pharm.D. and PGY1 (−10.990, p = 0.029) and R.Ph./Pharm.D. and PGY2 (−12.640, p = 0.010, adjusted p‐value) groups. Reported CDTM facilitators were job requirements, expanding patient care, job satisfaction/personal advancement, and expanding professional practice. Reported challenges were continuing education, clinical/interprofessional concerns, administration issues with the board of pharmacy or individual practice site, and regulations differing from other states.ConclusionOf those with CDTM licensure, a majority offer medication therapy management and chronic care management services covering diabetes, hypertension, and hyperlipidemia. Postgraduate training may help prepare pharmacists to engage in CDTM services.

USE OF CHRONIC CARE MANAGEMENT SERVICE AMONG MEDICARE BENEFICIARIES IN 2015-2019

Abstract The Centers for Medicare and Medicaid Services (CMS) introduced Chronic Care Management (CCM) services in 2015 for patients with multiple chronic diseases. Few studies examined the use of CCM services by demographic, geographic, and clinical characteristics. We used 2014-2019 Medicare claims data from a 5% random sample of fee-for-service beneficiaries aged 65 years or over and enrolled Medicare Part B. Of the approximately 1.4 million beneficiaries annually, approximately 75% were potentially eligible beneficiaries of CCM services who had been diagnosed with two or more chronic conditions before the year (2015: 1,073,729; 2016: 1,094,277; 2017: 1,106,929; 2018: 1,118,386; 2019: 1,130,523). The primary outcome was the rate of patients receiving CCM services among potentially eligible beneficiaries using CPT codes 99490, 99491, and 99487 in each year. Among the potentially eligible beneficiaries, the rate of patients receiving CCM services increased from 1.1% in 2015 to 3.4% in 2019 (2015: 11,480; 2016: 22,154; 2017: 31,890; 2018: 37,341; 2019: 38,863). CCM use was concentrated in the South (2015: Georgia: 1.4%; Vermont: 0.1%; 2019: Georgia: 6.1%; Vermont: 0.1%). The increase was higher in beneficiaries with ten or more chronic diseases than in those with two to five chronic diseases (2015: 2-5 chronic diseases: 0.7%; 10 + chronic diseases 2.0%; 2019: 2-5 chronic diseases: 2.1%; 10 chronic diseases: 7.0%), and higher in severely frail beneficiaries than in robust beneficiaries (2015: robust: 0.6%; severely frail: 3.3%; 2019: robust: 1.9%; severely frail: 9.4%). Variations were observed in the utilization of CCM services across demographic, geographic, and clinical characteristics.

Patient satisfaction with pharmacist-led chronic care management services combined with medication synchronization.

Chronic care management (CCM) improves clinical outcomes, enhances patients' adherence with medical treatments, reduces overall cost, and increases patient satisfaction. However, multiple reports have indicated the underutilization of CCM. Implementation literature has emphasized feasibility and different approaches to providing pharmacist-led CCM. This article examines patient acceptability and provides an innovative implementation approach combining both CCM and medication synchronization (MedSync) services. To introduce CCM services to underserved Medicare beneficiaries at a federally qualified health center, the pharmacy department of a federally qualified health center (FQHC) pilot tested a program whereby pharmacists provided CCM to Medicare beneficiaries enrolled in the MedSync service offered by the FQHC's in-house pharmacies. Both services were provided during the same phone call by the pharmacist. After successful completion of the pilot program, a retrospective chart review and patient satisfaction survey were conducted to enhance the quality of the service. A total of 49 patients were enrolled in the CCM program at the time of data collection. Overall, participants were satisfied with the service. The average number of medications per patient was 13.7. Pharmacists were able to identify an average of 4.8 medication-related problems (MRPs) per patient. Most of the MRPs (62%) were resolved directly by the pharmacists via education, over-the-counter medication adjustments, or interventions under consult agreements. In addition to positive patient satisfaction, pharmacists were able to identify and address a significant number of MRPs when providing CCM.

Financial reimbursement and productivity metrics for pharmacist-led chronic care management services in rural practice settings.

The implementation of chronic care management (CCM) services has often been hindered by issues with reimbursement, raising concerns about sustainability. To date, little if any literature has examined the financial feasibility and sustainability of CCM services in rural practice settings. Assess financial reimbursement and productivity metrics for pharmacist-led CCM services at a rural, medically underserved family medicine clinic. This study retrospectively examined data from the clinic's CCM program from October 2020 through May 2021 and included total clinical encounters, minutes of pharmacist time spent on calls, CCM claims, work relative value units (wRVU), financial reimbursement, and overall personnel costs. Over an 8-month period, 46 patients were enrolled in CCM services. Of the 49 CCM calls placed during this time, 31 (63.3%) were billable, though only 20 (64.5% of billable calls) were ultimately reimbursed. Approximately 37% of pharmacist "time-on-task" was not billable. Compared to the $643 required to cover pharmacist time on CCM calls, $822 of reimbursement was collected. This $179 profit, or 27.8% return-on-investment, is similar to results from more urbanized practices. Furthermore, services were "net productive" in wRVU generation, which may appeal to physician stakeholders interested in such targets. Concerns about profitability and sustainability have prevented more widespread CCM implementation. In the present study, pharmacist-led CCM services achieved a 27.8% return-on-investment. Though rural-based CCM services may never attain significant profit margins, this data suggests they can still be financially self-sustaining and "net productive," all while providing high-quality patient care.

Community Pharmacist and Family Medicine Collaboration for Pre-Visit Planning for Shared Patients Receiving Chronic Care Management Services

Background: Pre-visit planning entails completing necessary tasks prior to clinic appointments. Community pharmacists (CPs) have unique knowledge about patients’ medication use but do not routinely provide drug therapy reviews before clinic visits. Objectives: (1) Create and implement a business partnership between a CP and family medicine clinic (FMC) for CP provision of pre-visit medication reviews, and (2) describe the billing experience for shared patients in the FMC chronic care management (CCM) program. Methods: A prospective 8-month study in one community pharmacy and FMC in Iowa. Eligible patients were enrolled in the clinic CCM program and received their prescriptions at the CP. CPs were granted access to the clinic electronic health record (EHR), performed medication reviews, and recorded drug therapy recommendations (DTRs) in the clinic EHR. FMC physicians reviewed CP DTRs before the patient encounter. Time tracking software in the EHR recorded CP and FMC time performing CCM services. CCM revenue was prorated between parties. FMC physicians completed a survey about their experience. Results: Overall, there were 129 CP reviews performed for 95 patients. These reviews resulted in 169 DTRs and 76% were accepted by the physician. There were 71 CCM claims billed and CCM revenue was $3596 ($1796 FMC, $1800 CP). More than 90% of physicians (N = 11) indicated they reviewed CP DTRs before the patient encounter and agreed they were helpful to their practice. Conclusion: CPs completed pre-visit medication reviews and made accepted medication therapy recommendations. CCM billing provided a mechanism for CPs to receive revenue for their services.

A Pilot to Implement Chronic Care Management Services at an Academic Medical Center.

Objective: Chronic Care Management (CCM) for patients requires care coordination. Our aim was to describe a pilot to implement CCM services within our house call program. We aimed to identify processes and verify reimbursement. Design: Pilot study and retrospective review of patients participating in CCM. Setting and Participants: Non-face-to face delivery of CCM services at an academic center. Sixty-five and over with two or more chronic conditions expected to last at least 12 month or until the death of the patient from July 15th, 2019 to June 30, 2020. Methods: We identified patients using a registry. If consent given, a care plan was documented in the chart and shared with the patient. The nurse would then call the patient during the month to follow up on the care plan. Results: Twenty-three patients participated. Mean age was 82 years. Majority were white (67%). One thousand sixty-six dollars ($1,066) were collected for CCM. Co-pay for traditional MCR was $8.47. Most common chronic disease diagnoses were hypertension, congestive heart failure, chronic kidney disease, dementia with behavior and psychological disturbance, and type 2 diabetes mellitus. Conclusion and Implications: CCM services offer additional revenue source for practices that provide care coordination for chronic disease management.

Utilization of Medicare's chronic care management services by primary care providers

BackgroundMedicare billing codes introduced in 2015 reimburses primary care providers for non-face-to-face, chronic care management (CCM) services rendered by clinical staff. PurposeThe purpose of this manuscript was to describe provider trends in billed CCM services and identify factors associated with CCM utilization. MethodsObservational study using Medicare Public Use Files, 2015 to 2018. General, family, geriatric, and internal medicine physicians, nurse practitioners (NPs), and physician assistants (PAs) with billed primary care services were included. Multivariable analyses modeled associations between the CCM services and type of provider, adjusting for year, primary care services, practice, and patient characteristics. FindingsAmong 140,465 physicians and 141,118 NPs/PAs, CCM services increased each year, yet remained underutilized: 2% to 7% of physicians and 0.3% to 1.3% of NPs/PAs billed CCM in 2018. Increases in beneficiaries (p < .0001), percentage of dually enrolled (p = .0134), and primary care services (p < .0001) predicted higher CCM utilization. DiscussionCCM utilization reflects practice-based efforts to improve patient access to care by enhancing care delivery.

Evaluating the Efficacy of 3 Recruitment Methods for Enrolling Patients in Chronic Care Management Services: A Pilot Study.

Chronic Care Management (CCM) is a billable service that pharmacists can provide either in person or via telephone in ambulatory clinics or community pharmacies. Pharmacists may use this service to expand current roles in patient care and add billable services to an ambulatory care practice. The number of clinics employing CCM is steadily increasing, and to date, there has been limited information published to aid pharmacists who are considering implementing these services. The purpose of this study is to compare enrollment success in a clinic-based, pharmacist-led CCM service using three recruitment strategies to enroll patients: in person, telephone, and provider referred recruitment. This pilot study examined the success of three recruitment strategies using 94 patients eligible for CCM services in a rural health clinic. The primary outcome was successful enrollment in the CCM program with differences in recruitment strategy enrollment success examined using a Chi-square test. Overall, 42 of 94 patients (45%) were successfully enrolled in the CCM program with no statistical difference appreciated between telephone, in person, and provider referred recruitment. Nearly 33% (14/42) of patients enrolled in person, 40% (17/42) enrolled via telephone, and 26% (11/42) enrolled when referred from a provider. Ten patients (11%) declined enrollment outright. The remaining 42 patients were hesitant to enroll and requested follow up. In conclusion, there was no statistical difference in CCM enrollment success with in person, telephone, or provider referred recruitment, although more patients were enrolled via telephone than with the other two strategies. Pharmacists implementing new CCM programs may tailor their recruitment and enrollment strategy to suit their specific needs.

Improvement in Clinical Outcomes and Access to Care With Pharmacist-Led Chronic Care Management Services at a Rural Family Medicine Clinic

Background: Chronic care management (CCM) can significantly impact the management of chronic diseases in rural patient populations. To date, few practice models have addressed its impact on clinical outcomes and access to care in rural practice settings. Objective: Implement a sustainable pharmacist-led CCM practice model while tracking clinical outcomes and healthcare access at a rural, medically underserved family medicine clinic. Methods: This study retrospectively examined data from the clinic’s CCM program from October 2020 through May 2021 and included total clinical encounters at three- and 6-months intervals, as well as changes in clinical outcomes like A1c and systolic blood pressure (SBP) at three- and 6-months intervals. Results: Over an 8-month period, 46 patients were enrolled in pharmacist-led CCM services. Those with a CCM encounter or office visit within 3 months of enrollment showed a mean A1c reduction of 1.07% after 3 months (95% CI −1.70 to −.44, P = .0016), while those with an encounter or office visit within 6 months of enrollment displayed a mean A1c reduction of 1.64% after 6 months (95% CI −2.35 to −.92, P < .001). There was a 73.8% increase in total clinical encounters in the 6 months after CCM enrollment compared to the 6 months preceding it, signifying increased access to care. Conclusion: Patients with CCM encounters or office visits within the first 3-6 months experienced statistically significant reductions in A1c. Moreover, total clinical encounters markedly increased in the 6 months after enrollment, allowing for more frequent engagement between ambulatory pharmacists and traditionally challenging rural patients.

Chronic Care Management for 2 or More Conditions: 2022 Changes

The codes and instructions for reporting chronic care management (CCM) services continue to evolve.

Association of Team Structure and Chronic Disease Outcomes: Biomarker Evidence from U.S. Primary Care Clinics

Research ObjectiveThe quality of chronic disease management is highly variable and low on average. As chronic care is increasingly delivered by teams instead of solo providers, an important yet unresolved question concerns the structure of teams that tend to perform best. Optimal team structure likely depends on the mechanisms by which team‐based care may improve outcomes. Mechanisms that may favor larger, more diverse teams include more frequent patient touchpoints, complementarities between team member skill, or a higher chance of developing a strong patient‐provider relationship. Conversely, coordination costs or diffusion of responsibility may cap the optimal team size. We examine the relationship between team structure and chronic disease outcomes.Study DesignAnalysis of patient outcomes by team structure (i.e., number and types of providers seen) using rich, de‐identified EHR data. We classify teams by constructing a measure analogous to the Herfindahl–Hirschman Index (HHI) to assess provider concentration across a patient's primary care visits. Our chronic disease outcomes include biomarkers that often determine clinical decision‐making, including hemoglobin A1c, blood pressure, and LDL cholesterol, as well as process measures. First, we compare outcomes for patients who receive care from solo providers (HHI 10,000), concentrated teams (5000 &lt; HHI &lt; 10,000), balanced teams (HHI 5000), and diffuse teams (HHI &lt; 5000), adjusting for organization fixed effects and baseline disease biomarkers. Second, we identify the effect of team‐based care by studying practices that switch from solo to team‐based care, using a difference‐in‐differences design.Population Studied&gt;10 million primary care visits of &gt;1.2 million patients cared for by ~2000 providers at &gt;250 practices part of the athenahealth network from 2013–2018.Principal FindingsTaking diabetes as an example, we find that 75.7% of patients with new‐onset disease receive care from a solo provider, 12.3% from a concentrated team, 8.5% from a balanced team, and 3.5% from a diffuse team. We find that process measures differ by team structure, with solo providers ordering fewer A1c tests and prescribing fewer anti‐diabetics, compared to concentrated and diffuse teams, but not compared to balanced teams. Finally, we find that solo providers are less likely to bring their patients' diabetes under control compared to diffuse teams, but not compared to balanced or concentrated teams.ConclusionsPerformance differed by team concentration, suggesting that optimal team structure may trade off team size and frequency of visits per team member. Our study is the first, to our knowledge, to investigate the effect of different team structures on individual biomarker‐level outcomes.Implications for Policy or PracticeOur results may provide insights about the most effective team structures for increasingly consolidated primary care practices (e.g., PCMHs and ACOs). For practices seeking to adopt a team‐based care model, team structure is a potentially important factor to consider when deciding on staffing models. For payers, our results suggest that novel care coordination incentives, such as the CMS Chronic Care Management Services CPT code introduced in 2015, can be designed and further improved upon to encourage team structures that optimize the value of team‐based care.

RE4 The IMPACT of Reimbursement for NON-Face-to-Face Chronic Care Management on Health Outcomes and Health Care Utilization Among Patients with Type 2 Diabetes in Louisiana

This study aimed to evaluate the impact of non-face-to-face chronic care management (NFFCCM) services on multiple health outcomes and utilizations among Medicare beneficiaries with diabetes in Louisiana Type 2 diabetes patients with Medicare as their primary payer at baseline were extracted using 2013 to early 2020 electronic health records from the Research Action for Health Network (REACHnet) database. The treatment cohort was defined by the index NFFCCM codes: 99490 or complex NFFCCM codes: 99487, and 99489. Group-based trajectory balancing and propensity score matching was used to obtain comparable treatment (with NFFCCM) and control (without NFFCCM) groups at baseline. The primary outcome is glycemic control measured by hemoglobin A1c (HbA1c). Secondary outcomes include health utilization (outpatient visits, emergency department visits, and inpatient admissions) and diabetic complication rates (coronary heart disease, stroke, and major adverse cardiovascular events). We tested each of these outcomes across various frequencies of NFFCCM receipt over 6 and 12 months. We found a positive impact of NFFCCM on diabetes management in a well-balanced sample. Receiving any NFFCCM was associated with a reduction in HbA1c of 0.058% (P<0.001), an increase in outpatient visits of 0.723 (p<0.001) per month, a decrease in inpatient admissions of 0.006 (p<0.001) per month, and a decrease in ED visits of 0.003 (p<0.001) per month during a 24-month follow-up period after the first NFFCCM encounter. After receiving NFFCCM, treated individuals were 2.1% (p<0.001) more likely to have an HbA1c less than 7% during a 24-month follow-up period after the first NFFCCM encounter. Both complex and non-complex NFFCCM significantly increased visits to outpatient services and decreased inpatient admissions. We did not find significant improvements in diabetic complication outcomes. Our analysis found NFFCCM was associated with better glycemic control, more outpatient visits, fewer inpatient admissions, and fewer ED visits among patients with type 2 diabetes

Analysis of provider-generated revenue and impact on medication reconciliation from a pharmacist-led chronic care management service

BackgroundPublished data on pharmacist-provided chronic care management (CCM) services is limited, particularly for programs led by community-based pharmacists. ObjectiveThe objective was to quantify the total revenue generated from a community pharmacist-led CCM service, including CCM billing and appointment referrals. A second objective was to identify the types and frequencies of medication discrepancies identified during medication reconciliation. Practice descriptionRealo Drugs is a group of 18 independent community pharmacies serving eastern North Carolina. Practice innovationExploration of revenue generated from a community pharmacist-led CCM service. Evaluation methodsThis retrospective analysis assessed interventions completed by pharmacists between April 1, 2018 through June 30, 2019. Data was extracted from the electronic health record (EHR), including revenue generated from CCM billing codes, appointment referrals made by the pharmacist resulting in a completed in-office appointment, and which patients received medication reconciliation. The types and frequencies of medication discrepancies were documented, including medication no longer being used by the patient, medication omission, and strength or dose mismatch. Descriptive statistics were used to analyze data. ResultsOver 15 months with a total of 112 patients, a total of $26,148 was generated from CCM services, representing an average of $15.56 per patient per month. The majority (approximately 80%) of the revenue was generated from noncomplex patient encounters. Of the 239 medication reconciliations completed, 609 medication discrepancies were identified. The majority of medication discrepancies (67%) were categorized as “patient no longer takes medication listed on EHR medication list.” The second most common discrepancy was “patient takes medication not listed on the EHR medication list” (22%), followed by “strength/dose mismatch” (10%). ConclusionThese data can demonstrate to provider partners the sources of revenue that can be provided through CCM services. In addition to revenue, pharmacists can positively impact patient care through identification of medication discrepancies through medication reconciliation.

Virtual care for cyber–physical systems (VH_CPS): NODE-RED, community of practice and thick data analytics ecosystem

Virtual care is changing from the mere Face-to-Face Services, which includes telephone visits in addition to audio and video visits to include several non Face-to-Face Services, including E-visits, community of practice consultations and remote Patient Monitoring (RPM). Virtual care has the capacity to transform how people interact and collaborate with each other using the cyber–physical systems’ services. However, the use of cyber–physical​ systems (CPS) in healthcare is still in its infancy and there exist many challenges to be solved. The future of virtual care based on CPS will be require the availability of an ecosystem that leverages range of technologies to enable care to shift away from the legacy clinical setting when appropriate. In order to provide such open loop type of connectivity and interfacing, this article presents a solution VH_CPS ecosystem that push beyond the telehealth visit to create an ecosystem that integrates the care team collaboration with other essential virtual services such as remote monitoring and diagnostics as well as chronic care management services. Moreover, this article incorporate at VH_CPS ecosystem a component that enables the care team to assist in driving more in depth analytics based on qualitative techniques borrowed from the paradigm of thick data analytics. The Siamese Neural Network used in this paper is an example where care team members like a radiologist can feed few labelled CT-Scans to let the decision making component of the VH_CPS to learn the diagnosis of COVID cases. Our VH_CPS ecosystem uses a scalable Node-RED framework with the care team as well as to the remote patient monitoring devices. Our ecosystem will enable more patients to access the care they need, keep more patients in a low-risk care setting, and contribute to better outcomes at lower costs.

Effect of a standardized module for training pharmacy technicians to assist with chronic care management services

ObjectiveTo measure the change in knowledge of a certified pharmacy technician (CPhT) after completing a standardized educational module highlighting key information required to complete chronic care management services. SettingSeven independent community pharmacy locations. Practice descriptionRealo Discount Drugs is a group of 19 independent community pharmacies serving eastern North Carolina. Practice innovationThree modules were created to educate CPhTs: (1) basics of chronic care management, (2) medication and vaccination reconciliation and screening tools, and (3) assessing chronic diseases and setting goals. Each module averaged 10 minutes and was in the form of voice-over Microsoft PowerPoint (Microsoft Corporation, Redmond, WA) slides. EvaluationThe CPhTs anonymously took a computerized 20-question pretest before viewing the modules. The CPhTs were asked to view the modules within 7 days of completing the pretest. After at least 14 days of module completion, the CPhTs anonymously took the same computerized 20-question posttest and a 3-question survey. Pre- and posttest scores were compared using a paired t-test. ResultsA total of 12 participants completed the study. The mean pretest score was 60% (12/20 points), the mean posttest score was 75% (15/20 points), the mean difference between pre- and posttest scores was an increase of 15% (3 points), and this difference was statistically significant (P = 0.004). There were 10 CPhTs who had an increase in score from pre- to posttest. Most of the CPhTs found the modules to be informative and to have value in increasing their abilities and responsibilities in performing as CPhTs. Some of the CPhTs reported using the learned information daily. ConclusionThese standardized modules were effective in increasing clinical knowledge of the CPhTs for completing chronic care management services. New topics can be added in the future, as well as following up with CPhTs on missed questions and knowledge application.

Medicare's Care Management Codes Might Not SupportPrimary Care As Expected.

To enhance compensation for primary care activities that occur outside of face-to-face visits, the Centers for Medicare and Medicaid Services recently introduced new billing codes for transitional care management (TCM) and chronic care management (CCM) services. Overall, rates of adoption of these codes have been low. To understand the patterns of adoption, we compared characteristics of the practices that billed for these services to those of the practices that did not and determined the extent to which a practice other than the beneficiary's usual primary care practice billed for the services. Larger practices and those using other novel billing codes were more likely to adopt TCM or CCM. Over a fifth of all TCM claims and nearly a quarter of all CCM claims were billed by a practice that was not the beneficiary's assigned primary care practice. Our results raise concerns about whether these codes are supporting primary care as originally expected.

Community pharmacist and family medicine clinic provision of chronic care management services for Medicare beneficiaries with uncontrolled hypertension

AbstractIntroductionPharmacist‐physician collaboration has shown positive results in improving patient outcomes. Chronic care management (CCM) is a reimbursable service for Medicare beneficiaries in the community setting which includes comprehensive care management and other activities. The pharmacist contribution to CCM services and their associated impact on patient health outcomes has not been fully explored.ObjectivesThe objectives of this study were to: (a) implement a collaborative CCM service between a community pharmacy and family medicine clinic for their common hypertensive patients; (b) measure blood pressure change for patients receiving the CCM intervention; and (c) report financial viability for the community pharmacy and family practice clinic partnership.MethodsSingle group prospective pilot intervention in an independent community pharmacy and family medicine clinic in a small city in the Midwest United States. Forty‐five patients with uncontrolled hypertension who are patients to both community pharmacy and clinic were recruited, and 26 received CCM interventions in person or over the telephone from the community pharmacists to manage medications for hypertension. Our main outcomes were blood pressure values and financial viability.ResultsTwenty‐six patients received at least one community pharmacist encounter. These patients had an average 7.3 mm Hg decline (P = .006) in systolic blood pressure (SBP) and a 2.4 mm Hg decline (P = .079) in diastolic blood pressure (DBP) at 9 months. The total revenue over the study period was $5842. Total revenue for the community pharmacy and clinic was $2785 and $3057, respectively.ConclusionThe community pharmacy/clinic collaboration resulted in improved blood pressure control, a new source of revenue for the community pharmacy, and increased revenue for the clinic. Further research is needed on CCM revenue sharing between physicians and pharmacists to generalize the results.

Example: My Plan of Care (Online Exclusive)

Creating templates for plans of care and tracking the time and activities of chronic care management (CCM) services require time and effort but are essential to providing and documenting these services.