Care management services are an important part of a patient’s medical home experience. While under their pediatrician’s care, in many cases, a child will require other specialists, providers, and clinical visits to ensure their conditions are well-managed. In this post, we’ll take a look at the differences between complex care cases and ways your practice can best approach them.
Care management services are required when a patient is receiving ongoing care, whether that care is received via a hospital, assisted living facility, or at home. Care management services carry plenty of benefits for both practices and families: when the supervising pediatrician coordinates care between multiple providers or clinical staff, it can reduce avoidable expenses for families, improve engagement with the patient, and reduce care fragmentation. A win for patients and pediatricians!
Since the primary care provider is the supervising physician for a patient’s care, even while they receive care from other sources, the care plan is ultimately the responsibility of the pediatrician. Tasks will include modifying and updating the patient’s care plan, coordinating care between other providers and professionals, and engaging with the patient and their family about their care plan, prognosis, and resources.
There are three formal definitions of care management for a patient with complex or chronic care needs. These definitions are important for accurate coding. For more information on billing for care management of the complex patient, check out our webinar, where Brian Kennedy, CPC-A walks you through each step to ensure you’re being paid what you deserve.
Many physicians will be familiar with principal care management, in which one chronic condition is addressed. Chronic care management is defined as two or more chronic conditions. Complex chronic care management, on the other hand, requires that all of the patient’s conditions require high medical decision-making, and are anticipated to last at least 12 months or until the patient’s death.
The Agency for Healthcare Research and Quality, a part of the Department of Health and Human Services, recommends three strategies for care management: one, to identify populations with modifiable risks; two, to align services to the needs of the population; and three, to identify, prepare, and integrate appropriate personnel to deliver the needed services. While each patient’s case, especially if complex, may be personalized depending on their needs, looking at care management as a healthcare practice can help optimize solutions that can help many patients.
Populations with modifiable risk factors are opportunities for your practice to deliver care management services to best improve health across communities. For example, your practice might decide that better communication with school specialists such as guidance counselors and speech-language pathologists is necessary for improved care. Setting a meeting with schools in your community to review multiple patients could improve case management.
Over time, patients will need modifications to their care plans, which is a chance for your practice to consider widespread changes. For example, the patients with a high likelihood of managing their own care, such as following a diet plan, therapy regimen, or mental health practice, need less involved case management than patients with a low likelihood to follow their care plan.
Finally, delegation of care. For a large practice, this might involve hiring a care coordinator whose primary responsibility is to handle care management services for patients. For many practices, this will simply involve identifying which tasks are more efficient for staff to do versus which tasks must be performed by a physician. Practices should note that billing for staff time and physician time is an important distinction to ensure proper payment.
As the primary care provider, pediatricians are the locus between the services that help a child’s whole person health, as well as the safe place families return to for reassurance and information. A robust medical home saves families the stress and anxiety of managing care while remaining the place caregivers can go to for support.
Whether you’re ready to revamp your practice’s care management services or you’re already leading a great, communicative team of professionals across services, knowing how to bill correctly for care management services is a critical step. Make sure you’re being paid what you deserve for complex care patients by checking out our webinar: Managing Care for the Complex Patient… And Getting Paid for It.