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1 Implementing High Quality Telephone Care in Pediatric Practice Randall Sterkel MD Medical Director Call Center St. Louis Childrens Hospital QuIIN QI.

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Presentation on theme: "1 Implementing High Quality Telephone Care in Pediatric Practice Randall Sterkel MD Medical Director Call Center St. Louis Childrens Hospital QuIIN QI."— Presentation transcript:

1 1 Implementing High Quality Telephone Care in Pediatric Practice Randall Sterkel MD Medical Director Call Center St. Louis Childrens Hospital QuIIN QI Conference Call Series for Network Members July 24, 2009

2 2 Implementing High Quality Telephone Care in Pediatric Practice: Telephone Care is Common 2,000-3,000 calls/yr/MD 2,000-3,000 calls/yr/MD 10-15 clinical calls/day/MD 10-15 clinical calls/day/MD 20% in-office care 20% in-office care 80% after-hours care 80% after-hours care 27% of decisions to see a subspecialist made over the phone 27% of decisions to see a subspecialist made over the phone Significant chronic care disease management done over the phone Significant chronic care disease management done over the phone

3 3 Implementing High Quality Telephone Care in Pediatric Practice : Telephone Care is Increasing Easy Easy Convenient Convenient Safe Safe Dual-working families Dual-working families Doctors pushed to see more patients Doctors pushed to see more patients Cost-efficient Cost-efficient

4 4 Implementing High Quality Telephone Care in Pediatric Practice : Telephone Care is Safe Goal of study to assess: Goal of study to assess: (1) frequency of death or potential under-referral associated with hospitalization within 24 hours after a call, and (2) factors associated with potential under-referral. Results: Results: No deaths occurred within < 1 week after the after-hours calls.No deaths occurred within < 1 week after the after-hours calls. Rate of potential under-referral with subsequent hospitalization was 0.2%, or 1 case per 599 triaged callsRate of potential under-referral with subsequent hospitalization was 0.2%, or 1 case per 599 triaged calls Source: Pediatrics. 118(2):457-63, 2006

5 5 Implementing High Quality Telephone Care in Pediatric Practice : Telephone Care is Cost-Effective The provision of after-hours telephone care results in an average savings for payers of $56 per call The provision of after-hours telephone care results in an average savings for payers of $56 per call Pediatrics 2007; 119: e305-e313Pediatrics 2007; 119: e305-e313

6 6 Implementing High Quality Telephone Care in Pediatric Practice: Quality Improvement in Telephone Care Quality of Care The degree to which health care services for individuals and populations increase the likelihood of desired outcomes and are consistent with current professional knowledge. IOM 1990

7 7 Implementing High Quality Telephone Care in Pediatric Practice: Quality Improvement in Telephone Care Quality Improvement A key component of quality improvement science is addressing unwarranted variation in care and outcomes which are often due to inconsistent adherence by health care providers to evidence-based approaches to care, reflecting problems in the system for health care delivery IOM 2001

8 8 Implementing High Quality Telephone Care in Pediatric Practice: Telephone Care is Evidence-Based Pediatric Telephone Protocols Pediatric Telephone Protocols Office Version and After-Hours Version Office Version and After-Hours Version Barton Schmitt MD FAAP Barton Schmitt MD FAAP

9 9 Implementing High Quality Telephone Care in Pediatric Practice: Telephone Care Documentation Purpose of Documentation Purpose of Documentation Continuity of careContinuity of care Meet requirements of E/M visit or care plan oversight for coding/billingMeet requirements of E/M visit or care plan oversight for coding/billing Content of Documentation Content of Documentation Date and time of call, patients name, date of birth, reason for call, relevant history and evaluation, assessment, plan, disposition, total encounter timeDate and time of call, patients name, date of birth, reason for call, relevant history and evaluation, assessment, plan, disposition, total encounter time Location of Documentation Location of Documentation Chart and/or Telephone Log – must be retrievableChart and/or Telephone Log – must be retrievable

10 10 Implementing High Quality Telephone Care in Pediatric Practice: Services Appropriate for Telephone Care Triage Triage Acute Illness Care Acute Illness Care Chronic Disease Management Chronic Disease Management Medication Adjustments Medication Adjustments Test Result Interpretation Test Result Interpretation Counseling Counseling Patient Education Patient Education

11 11 Implementing High Quality Telephone Care in Pediatric Practice: Care Examples Acute Illness Care: Acute Illness Care: Conjunctivitis: Conjunctivitis: Purulent eye d/c +/- redness -> exclusion from school/daycare (Mo Dept Health)Purulent eye d/c +/- redness -> exclusion from school/daycare (Mo Dept Health) >70% purulent d/c due to bacterial conjunctivitis (J Peds, 1993)>70% purulent d/c due to bacterial conjunctivitis (J Peds, 1993) Child may return to school/daycare after starting eye drops (AAP, 2005)Child may return to school/daycare after starting eye drops (AAP, 2005) Careful Telephone treatment:Careful Telephone treatment: Speeds childs recovery and return to school/daycareSpeeds childs recovery and return to school/daycare Saves parent copay and possible missed workSaves parent copay and possible missed work Saves insurer balance of office visitSaves insurer balance of office visit

12 12 Implementing High Quality Telephone Care in Pediatric Practice: Care Examples Chronic Disease Management: Chronic Disease Management: ADD: ADD: PEDIATRICS Vol. 108 No. 4 October 2001, pp. 1033-1044 AMERICAN ACADEMY OF PEDIATRICS: Clinical Practice Guideline: Treatment of the School- Aged Child With Attention-Deficit/Hyperactivity Disorder Subcommittee on Attention-Deficit/Hyperactivity Disorder and Committee on Quality Improvement The clinician should periodically provide a systematic follow-up for the child being treated for ADHD. Plans for follow-up should include obtaining information through office visits and telephone calls.

13 13 Implementing High Quality Telephone Care in Pediatric Practice: Care Examples Chronic Disease Management: Chronic Disease Management: ADD ADD HEDIS 2009 Measure Follow-up care for Children Prescribed ADHD Medication An initiation phase visit in the first 30 days At least two follow-up visits from 31-300 days post-initiation. One of the three visits may be a telephone visit with a practitioner CPT Codes 99441-2 added to identify telephone visits

14 14 Implementing High Quality Telephone Care in Pediatric Practice: Care Examples Chronic Disease Management: Chronic Disease Management: ADD ADD ADD Telephone Care Visit Form ADD Telephone Care Visit

15 15 Implementing High Quality Telephone Care in Pediatric Practice: Care Examples Chronic Disease Management: Chronic Disease Management: Depression/Anxiety Depression/Anxiety Constipation Constipation Atopic Dermatitis Atopic Dermatitis Asthma Asthma

16 16 Implementing High Quality Telephone Care in Pediatric Practice: Physician Care Codes 99441 5-10 minutes of medical discussion 99441 5-10 minutes of medical discussion RVU:.36 RVU:.36 9944211-20 minutes of medical discussion 9944211-20 minutes of medical discussion RVU:.66 RVU:.66 99443>20 minutes of medical discussion 99443>20 minutes of medical discussion RVU:.98 RVU:.98

17 17 Implementing High Quality Telephone Care in Pediatric Practice: Nonphysician Care Codes 989665-10 minutes of medical discussion 989665-10 minutes of medical discussion 9896711-20 minutes of medical discussion 9896711-20 minutes of medical discussion 98968>20 minutes of medical discussion 98968>20 minutes of medical discussion Same RVUs as MD-provided careSame RVUs as MD-provided care

18 18 Implementing High Quality Telephone Care in Pediatric Practice: Telephone Coding Rules Telephone services are non-face-to-face evaluation and management (E/M) services provided using the telephone. Telephone services are non-face-to-face evaluation and management (E/M) services provided using the telephone. These codes are used to report episodes of care by the physician (or RN) initiated by an established patient or guardian of an established patient. These codes are used to report episodes of care by the physician (or RN) initiated by an established patient or guardian of an established patient. If the telephone service ends with a decision to see the patient within 24 hours or next available urgent visit appointment, the code is not reported; rather the encounter is considered part of the preservice work of the subsequent E/M service, procedure, and visit. If the telephone service ends with a decision to see the patient within 24 hours or next available urgent visit appointment, the code is not reported; rather the encounter is considered part of the preservice work of the subsequent E/M service, procedure, and visit.

19 19 Implementing High Quality Telephone Care in Pediatric Practice: Telephone Coding Rules Likewise if the telephone call refers to an E/M service performed and reported by the physician within the previous 7 days (either physician requested or unsolicited patient follow-up) or within the postoperative period of the previously completed procedure, then the service(s) are considered part of that previous E/M service or procedure. Likewise if the telephone call refers to an E/M service performed and reported by the physician within the previous 7 days (either physician requested or unsolicited patient follow-up) or within the postoperative period of the previously completed procedure, then the service(s) are considered part of that previous E/M service or procedure. Do not report 99441-99443 if reporting 99441-99443 performed in the previous 7 days. Do not report 99441-99443 if reporting 99441-99443 performed in the previous 7 days.

20 20 Implementing High Quality Telephone Care in Pediatric Practice: Care Plan Oversight Codes - Home Setting Care Plan Oversight – patient not under the care of a home health agency, hospice, or nursing facility Care Plan Oversight – patient not under the care of a home health agency, hospice, or nursing facility Individual physician supervision of a patient in home… (or other location)… requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans…communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s)…involved in the patients care… including adjustment of medical therapy, within a calendar month; Individual physician supervision of a patient in home… (or other location)… requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans…communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s)…involved in the patients care… including adjustment of medical therapy, within a calendar month; 99339 - 15-29 minutes 99339 - 15-29 minutes 99340 - >30 minutes 99340 - >30 minutes

21 21 Implementing High Quality Telephone Care in Pediatric Practice: Care Plan Oversight Implementation Develop a Tracking System- Document all CPO activities in chart based on time Document all CPO activities in chart based on time Maintain a list of patients with CPO activity Maintain a list of patients with CPO activity Pull Charts and tally all minutes at the end of a calendar month Pull Charts and tally all minutes at the end of a calendar month Educate families about billing Educate families about billing

22 22 Implementing High Quality Telephone Care in Pediatric Practice : Payment for Telephone care How Do You Get Started? AAP Payment for Telephone Care Toolkit Useful tools for implementation Useful tools for implementation Provides a handy Timeline to Going Live Provides a handy Timeline to Going Live Free download to AAP members on Practice Management Online website Free download to AAP members on Practice Management Online website

23 23 Implementing High Quality Telephone Care in Pediatric Practice : Reasons Supporting National Trend for Telephone Care Equivalent healthcare outcomes at lower costs Equivalent healthcare outcomes at lower costs Affordable to payers and patients Affordable to payers and patients Widespread adoption of medical home model and reliance upon PCP Widespread adoption of medical home model and reliance upon PCP Relieving pressures on overcrowded, understaffed hospital EDs for nonurgent care Relieving pressures on overcrowded, understaffed hospital EDs for nonurgent care Expanded practice options and paid accessibility for physicians Expanded practice options and paid accessibility for physicians Patient-centered care (giving consumers flexibility and options when the choice is safe, reasonable, and appropriate) Patient-centered care (giving consumers flexibility and options when the choice is safe, reasonable, and appropriate) Source: A Model for Telephone Medical Consults Guidelines for Decision-Makers, April 2008, Tommy G. Thompson et al Source: A Model for Telephone Medical Consults Guidelines for Decision-Makers, April 2008, Tommy G. Thompson et al

24 24 Using Telephone Care for Children with a Chronic Disease: Asthma Carolyn M. Kercsmar, MD Cincinnati Childrens Hospital Medical Center QuIIN QI Conference Call Series for Network Members July 24, 2009

25 25 Care Plan Oversight: Definition Individual physician supervision of a patient in home Individual physician supervision of a patient in home Patient not under the care of a home health agency, hospice, or nursing facilityPatient not under the care of a home health agency, hospice, or nursing facility Requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans…communication (including telephone calls) Requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans…communication (including telephone calls) for purposes of assessment, orfor purposes of assessment, or care decisions with health care professional(s), family member(s)…involved in the patients carecare decisions with health care professional(s), family member(s)…involved in the patients care adjustment of medical therapy,adjustment of medical therapy, within a calendar month within a calendar month 99339 (15-29 minutes) 99340 – (>30 minutes) 99339 (15-29 minutes) 99340 – (>30 minutes)

26 26 Types of Calls Call involves: Call involves: Services that involve a new treatmentServices that involve a new treatment Chronic medication managementChronic medication management Chronic disease flare managementChronic disease flare management Reporting lab results that necessitate a management change or referralReporting lab results that necessitate a management change or referral Extended behavioral counselingExtended behavioral counseling Follow-up calls to an office visit, but…Follow-up calls to an office visit, but… Timing of call in relation to office visit Timing of call in relation to office visit Does not pertain to a recent or scheduled office visitDoes not pertain to a recent or scheduled office visit Follow-up call in place of an office visitFollow-up call in place of an office visit > 7 days since previous office visit for same condition > 7 days since previous office visit for same condition Prevents an office visitPrevents an office visit

27 27 CPO for Chronic Conditions Previously diagnosed Previously diagnosed Initial plan of care established Initial plan of care established Stepwise care plan and treatment adjustments required Stepwise care plan and treatment adjustments required Algorithms and/or monitoring tools available Algorithms and/or monitoring tools available Examples: Examples: ADHDADHD Constipation/encopresisConstipation/encopresis AsthmaAsthma

28 28 CPO for Chronic Conditions: Asthma Why is asthma a good model? Why is asthma a good model? Substantial morbiditySubstantial morbidity Micromanagement required for optimal controlMicromanagement required for optimal control Complex treatment regimensComplex treatment regimens Co-morbid conditions affect treatment and outcomesCo-morbid conditions affect treatment and outcomes Assessment tools and treatment algorithms availableAssessment tools and treatment algorithms available Guided self-management is effectiveGuided self-management is effective

29 29 CPO for Asthma: When Monitoring control Monitoring control Loss of control Loss of control Medication step-upMedication step-up Gain of control Gain of control Medication step downMedication step down Revision of treatment plan Revision of treatment plan Monitoring and assessing adherence Monitoring and assessing adherence Promoting self-management Promoting self-management Treatment of mild exacerbations Treatment of mild exacerbations

30 30 CPO for Asthma: How Use existing national guidelines and algorithms Use existing national guidelines and algorithms Systematic data collection and actions Systematic data collection and actions Clear goals for the management plan Clear goals for the management plan

31 31 Asthma Control The degree to which the manifestations of asthma (symptoms, functional impairments, and risks of untoward events) are minimized and the goals of therapy are met. The degree to which the manifestations of asthma (symptoms, functional impairments, and risks of untoward events) are minimized and the goals of therapy are met. ImpairmentImpairment RiskRisk ResponsivenessResponsiveness Severity: intrinsic intensity of disease Severity: intrinsic intensity of disease NAEPP Expert Panel Report 3, 2007

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33 33 Content of Asthma CPO Expectations about asthma Expectations about asthma Your asthma can be controlled Asthma Control Asthma Control Minimize daytime, nighttime symptoms Patients goals of treatment Patients goals of treatment Maximize activity Medications Medications What medications are you taking? Environmental Control Environmental Control Have you noticed anything at home or school that makes your asthma worse? EPR3, 2007

34 34 Content of Asthma CPO Patients treatment preferences Patients treatment preferences What problems have you had using your medications? Have you missed any of your medications? What questions do you have about your asthma action plan? Can we make it easier? Describe for me how you know when to call the doctor or go to the hospital Quality of Life Quality of Life What things does your asthma make difficult to do?What things does your asthma make difficult to do?

35 35 Content of Asthma CPO Teach or review all educational strategies: Teach or review all educational strategies: Self-assessment of asthma control Relevant environmental control or avoidance strategies (smoke, pets, dust, mold) Review all medications Use of written asthma action plan What to do when asthma gets worse What will happen at your next visit: What will happen at your next visit: Review action plan, proper medication and device use, a physical examination, (spirometry). EPR3, 2007

36 36 Control: Impairment

37 37 Long term control medication DoseDurationProblems ICS (daily dose) LTRA LABA Other Significant exacerbations NumberDatesNotes Exacerbations (number/month) Oral corticosteroid courses (number/year) Hospitalizations (number per year) Risk and Responsiveness

38 38 Assessment and Plan Assessment Control poor Inadequate Optimal Side Effects Prohibitive Acceptable Minimal Criteria met for step up (control worse, exacerbation in past 3 months) Criteria met for step down: (control adequate, stable for 3 months, not high-risk season, no active co-morbidity) Adherence: GoodFairPoorProblems: Treatment Plan Step up: level = Step down: level = Medication(s)/Dose __________________________________________________________ Follow up: weeks months by telephone office visit______

39 39 GoalsMetIn Progress Notes Decrease nocturnal symptoms Decrease daytime symptoms Decrease albuterol use Improve exercise tolerance Improve school/daycare attendance Identify triggers Avoid triggers Avoid attacks Self management goal Confidence acceptable (>7) Other

40 40 Coding Time Call Ended Call Duration 20 min CPT Code: Telephone Care 99441 (5-10 min) 99442 (11-20 min) 99443 (>20 min) Care Plan Oversight 99339 (15-29 min) 99340 ( 30 min) Provider signature (MD, DO,PNP, RN)

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43 43 Telephone Services 2008 Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 daysnot originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment;nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-30 minutes of medical discussion5-30 minutes of medical discussion Mild Asthma exacerbationMild Asthma exacerbation Assess, Treat, Follow up Assess, Treat, Follow up

44 44 Acute Asthma Care Assess: When is it mild? Assess: When is it mild? Dyspnea only with activityDyspnea only with activity PEFR >70%PEFR >70% No retractionsNo retractions No/minimal tachypneaNo/minimal tachypnea Little/no impairment of activityLittle/no impairment of activity Symptoms are usually cough, mild wheezeSymptoms are usually cough, mild wheeze At least partial response to albuterolAt least partial response to albuterol

45 45 Not for infants Not for those with severe, brittle disease or at risk of death from asthma Properly trained and equipped < 20% in this category need ER or hospital care EPR 3, 2007

46 46 CPT Code: 99441 (5-10 min) 99442 (11-20 min) 99443 (>20

47 47 Asthma Action Plan The colors of the traffic light will help you use your asthma medicines Date of DischargeNext Doctors Appointment Date: Time: Doctors NameDoctors Phone Number GO! (Green)Use these medicines EVERY DAY to prevent asthma attacks You have ALL of these: Breathing is good No cough or wheeze Sleeping through the night Can work or play MedicineHow Much to TakeWhen to Take it No Controllers Prescribed Before exercise, if needed:2-4 puffs of Albuterol inhaler with spacer or 1 neb treatment, 5-20 minutes before exercise CAUTION (Yellow)Keep taking daily medicines (above), and add You have ANY of these: Cough Wheeze Chest tight or shortness of breath Waking at night due to cough or trouble breathing MedicineHow Much to TakeWhen to Take it No Relievers Prescribed Albuterol 2 - 6 puffs of inhaler, or 1 nebulizer treatment Every 4 hours as needed for 24-48 hours Call your doctor if you need more than 12 puffs or 4 nebs in 24 hours If you need to use your Albuterol more than 2 times a week, or if the Albuterol is not helping, CALL YOUR DOCTOR! DANGER!! (Red)Take these medicines and call your doctor Your asthma is getting worse quickly: Albuterol is not helping within 15-20 minutes Breathing is hard and fast Ribs show Lips or fingernails are blue Trouble walking or talking MedicineHow Much to TakeWhen to Take it Albuterol 4 - 6 puffs of inhaler, or 1 nebulizer treatment Give Albuterol treatment every 15-20 minutes, up to 3 times in a row Get help from a doctor now! If you cannot contact your doctor, go to the ER or call 911. Do NOT wait! See your doctor within 3-5 days of an ER visit or hospitalization o items that trigger your asthma and things that could make your asthma worse: Tobacco

48 48 Summary Use CPO to monitor treatment of chronic asthma (99339, 99340) Use CPO to monitor treatment of chronic asthma (99339, 99340) Treatment changes: step up or downTreatment changes: step up or down Bridge between office visits and in person monitoringBridge between office visits and in person monitoring Management of mild exacerbations Management of mild exacerbations Telephone visit codes (99441, 99442, 99443)Telephone visit codes (99441, 99442, 99443)

49 49 Telephone vs In person Asthma Review bmj.com 2003;326:477 Telephone visits were 10 minutes shorter than office visits No difference in patient satisfaction


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