1. Adding a Health Education Specialist to Your Residency - The Story - Cone Family Medicine Residency Greensboro, NC

2. Presenters M. Lee Chambliss MD MSPH Professor of Family Medicine Susanne Lineberry, MPH, CHC, MCHES Manager of Population Health and Quality

3. A Health Educator (HE) can directly earn their salary (and more) in a fee for service environment A Health Educator can perform a wide range of roles A Masters Level Health Educator can fill a leadership position in Quality Improvement A Master Level Heath Educator can assist with resident education in Quality Improvement Goals

4. Give Numbers from our Experience – Dollars Generated – QI Improvement Discuss Evidence for Adding HE to a practice – See Handout Not Goals

5. A Story of Challenges, Solutions and Mission Creep #1 Medicare Annual Wellness Visits #2 Individual Patient Quality #3 Practice Population Management #4 Resident QI Education and Organization

6. Medicare Annual Wellness Visits – Seemed like an opportunity to improve patient care and generate revenue – Did not understand them – Were doing very few Who will learn about and provide the AWVs? Problem #1

7. Noticed that Medicare allowed Health Educators to perform Annual Wellness Visits (AWV) independent of direct physician involvement. Opportunity

8. Opportunity Quoting directly from Medicare: “Who may perform the AWV? A health professional, meaning a physician … a qualified non-physician practitioner … or a medical professional (including a health educator, registered dietitian, nutrition professional, or other licensed practitioner), or a team of such medical professionals who are working under the direct supervision of a physician, must furnish the AWV.” Resource: Medicare, The ABCs of providing the annual wellness visit, January 2012

9. Opportunity Medicare defines direct supervision as: “Direct supervision in the office setting means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed.”

10. What is a Health Educator (HE)? Person trained to act as a patient resource and educator Usually have a bachelors or masters degree in public health or community health Certified by National Commission for Health Education Credentialing = Certified Health Education Specialist (CHES)

11. Medicare wellness visits are reimbursed at approximately $100 If HE performs three of these visits per day (700 per year) they could generate $72,000 per year Median 2010 salary for a Health Educator was $45,830 plus benefits. The additional overhead for a practice required would be one office space. Position Justification

12. 1. Developed a job description for a Health Educator 2. Collaborated with a local institution - University of North Carolina at Greensboro Department of Public Health to identify potential applicants. 3. Hired a master prepared HE with an additional health coaching certification. 4. Created office space for HE. 5. HE started with AWV’s. First Steps

13. Learned about AWV documentation and billing Reached out to patients to schedule AWVs Performed the AWV and documentation and sent to PCP for review and bill submission Would often call patient as a follow-up on plans for health improvement – Weight loss – Exercise – Smoking Cessation Number of Completed and Reimbursed AWVs skyrocketed AWVs - Solution

14. Chronic Disease Management A large number of our patients with chronic diseases were not at goal Traditional provider-patient office visit model had struck out Often felt to be due to patient centered issues – life style, adherence etc How to involve our HE as a Health Coach but continue to generate revenue? Problem #2

15. What is a Health Coach? Person trained to work with patients and physicians to clarify health goals, motivate behavioral changes, create accountability and follow up. Often have a Health Coaching certificate No national certification Can be trained as a scribe and to conduct co- visits.

16. Co-Visit (Single Person Group Visit) Chronic Disease Patient not at goal PCP discusses with patient and sends referral to HE/HC HE contacts patient Patient comes in for appointment while HE and PCP are in clinic HE spends 30 minutes with patient working on medication adherence or behavior change PCP comes in for 2-5 minutes reviews medical management HE completes majority of note using patient completed disease specific templates PCP finishes note and bills Level 3 Several faculty and third year residents performed co-visits with our HE – add 1-2 pts per half day Performed approximately 75-100 over the next year

17. Practice Population Management – Looming PCMH Recertification – Meaningful Use Reporting – Private Insurers Quality Projects/Reporting = $ – ACO Quality Improvement Projects – Regional Quality Collaborative - I3 Who will learn about and organize our response to all of these new opportunities? Problem #3

18. What is a Practice Quality Coordinator? Person trained to assess, plan, implement/lead and evaluate practice patient quality measures Usually a Masters in Public Health or Community Health No formal national certification

19. PQC Solution Over next two years – Became Population Health and Quality Manager and Faculty appointment – Completed Meaningful Use attestation for all faculty providers – Lead and Organized our PCMH recertification – Helped other sites set up Medicare AWVs – Clinic lean project improvements- standardize room stocking, reducing paper waster, – Develop patient satisfaction survey/roll out – Reach out and read books for kids – Lead Clinic mammography improvement project – ACO Quality Projects – I3POP Participation – Retinal Scanning

20. Resident Quality Improvement Education AHEC Residencies Quality Improvement Competition FM RC encouraged projects Resident driven QI projects Who will help the residents develop, organize realistic QI projects and maintain their momentum? Problem #4

21. Health Educator – Coordinated last two years of 3 rd year QI projects – Education on AWV and Chronic Care Management – Educated on IHI principles

22. Health Education Specialist Roles RoleJob Description Health educatorConduct annual wellness visits and act as patient resource and educator. Health coachConduct co-visits; work with physician and patient to clarify health goals, motivate behavioral change, create accountability, and follow up Practice quality coordinator Assess, plan, implement, evaluate, and teach practice patient quality measures,

23. Hire a second full time HE – AWVs – Chronic Care Management – Co-Visits Study effects of HE – In our residency Assign specific providers to work directly with a HE – In private practices Embed a HE in a private practice Future Plans

24. A HES can perform many roles – Directly generate income – Medicare AWV and Chronic Care Management Private Insurer Initiatives – Improve Patient Quality Metrics One on one coaching with patients during CoVisits Organize and Lead FMC Quality Initiatives - Resident Education Teach QI principles Coordinate resident QI projects Where Find – Local University School of Public Health Bachelors – Health Coach and Health Educator Masters – Practice Quality Coordinator How To Sart – Start with direct income generation – Add more dutiesSummary

25. Lee.Chambliss@conehealth.com Questions? Thank You

26. We’ve seen 441 pts for AWVs April 2015-April 2016 Timeline: April 18, 2015 - 1st AWV October 2015 - 2nd Health coach hired January 2016 – began offering Intensive Behavioral Therapy (IBT) for Obesity March 2016 – 3rd Health Coach hired April 2016 – 4th and 5th Health Coach hired, opening services to 20 providers – plans to expand to external locations Patient feedback has been very positive. Providers are extremely pleased with services and improved quality and resource identification for our patients. I hope to be able to do a formal survey soon Melissa Kuhn, MA, CTTS, CCP Wellness Program Coordinator Pinehurst Medical Clinic mkuhn@pinehurstmedical.com Health Educators in Private Practice

27. Reimbursement Billable ServiceWho Performs Service Physician TimeHealth Education Specialist’s Time Reimbursement Rate* Initial Prevention Physical Exam (IPPE, Welcome to Medicare Visit) Physician + Health Education Specialist 15 minutes to meet with the patient. 45 minutes$156-165 Initial Annual Wellness Visit Health Education Specialist 2 minutes to review documentation 1 hour$161-170 Subsequent Annual Wellness Visit Health Education Specialist 2 minutes to review documentation 30 minutes$108-114 Health Coaching co-visits Physician + Health Education Specialist 4-8 minutes to meet with patient, complete note. 30 minutes plus weekly phone calls $43-107, depending on level of service charged

28. PQC for PCMH recertification Previous box clicking for PCP did not show improvement in patient’s health. Identified high risk sub-populations to focus on PCMH requirements. – ≥9 A1C – At high risk for falls – Ready to quit smoking – Two BP readings ≥ 160/100 PCP would identify and refer these patients to our HE after their visits. HE fulfill PCMH requirements, use MI skills and set health goals with patients. Patient follow up phone calls and appointments with HE Achieved PCMH Recertification Level 3, Improved A1c levels and much improved provider satisfaction

29. 2012 – Performed AWVs on 211/800 patients > 65 years old Billed $32,000 AWV no shows rate 16% – 25 co-visits 2013 – Performed AWVs on 129/1200 patients (all ages) – 50 co-visits – QI conference projects (I3POP) – Maternity Leave 2014 – Performed AWVs on 28/1200 – 50+ co-visits PCMH related – PCMH recertification – Meaningful Use, ACO, Resident QI projects, I3POP – 135 Retinal Scans Our Practice’s Timeline

30. 2015 – Retinal Scans – Became Population Health and Quality Manager and Faculty appointment – Completed MU attestation for all faculty providers – Current 3rd Year QI project-Narcotics 2016 – Clinic lean project improvements- standardize room stocking, reducing paper waster, – Develop patient satisfaction survey/roll out, – Reach out and read books for kids, – Clinic mammography improvement project. – Maternity Leave Our Practice’s Timeline