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Implementing High Quality Telephone Care in Pediatric Practice

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Presentation on theme: "Implementing High Quality Telephone Care in Pediatric Practice"— Presentation transcript:

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

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

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

4 Implementing High Quality Telephone Care in Pediatric Practice : Telephone Care is Safe
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: 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 calls Source: Pediatrics. 118(2):457-63, 2006

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 Pediatrics 2007; 119: e305-e313

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

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

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

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

12 Implementing High Quality Telephone Care in Pediatric Practice: Care Examples
Chronic Disease Management: ADD: PEDIATRICS Vol. 108 No. 4 October 2001, pp 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 Implementing High Quality Telephone Care in Pediatric Practice: Care Examples
Chronic Disease Management: 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 days post-initiation. One of the three visits may be a telephone visit with a practitioner CPT Codes added to identify telephone visits

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

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

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

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

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. 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.

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. Do not report if reporting performed in the previous 7 days.

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 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 patient’s care… including adjustment of medical therapy, within a calendar month; minutes >30 minutes

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 Maintain a list of patients with CPO activity Pull Charts and ‘tally” all minutes at the end of a calendar month Educate families about billing

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 Provides a handy Timeline to ‘Going Live” Free download to AAP members on Practice Management Online website

23 Implementing High Quality Telephone Care in Pediatric Practice : Reasons Supporting National Trend for Telephone Care Equivalent healthcare outcomes at lower costs Affordable to payers and patients Widespread adoption of medical home model and reliance upon PCP Relieving pressures on overcrowded, understaffed hospital EDs for nonurgent care Expanded practice options and paid accessibility for physicians 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

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

25 Care Plan Oversight: Definition
Individual physician supervision of a patient in home Patient 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) for purposes of assessment, or care decisions with health care professional(s), family member(s)…involved in the patient’s care adjustment of medical therapy, within a calendar month 99339 (15-29 minutes) – (>30 minutes) patient not under the care of a home health agency, hospice, or nursing facility

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

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

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

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

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

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. Impairment Risk Responsiveness Severity: intrinsic intensity of disease NAEPP Expert Panel Report 3, 2007

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

34 Content of Asthma CPO Patient’s treatment preferences Quality of Life
”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 “What things does your asthma make difficult to do?”

35 Content of Asthma CPO 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: Review action plan, proper medication and device use, a physical examination, (spirometry). EPR3, 2007

36 Control: Impairment

37 Risk and Responsiveness
Long term control medication Dose Duration Problems ICS (daily dose) LTRA LABA Other Significant exacerbations Number Dates Notes Exacerbations (number/month) Oral corticosteroid courses (number/year) Hospitalizations (number per year)

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: Good Fair Poor Problems: Treatment Plan Step up: level = Step down: level = Medication(s)/Dose __________________________________________________________ Follow up: weeks months by telephone office visit______

39 Goals Met In 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 Coding Provider signature (MD, DO,PNP, RN) Time Call Ended
Call Duration  <5min  5-10 min  min  >20 min CPT Code: Telephone Care  (5-10 min)  (11-20 min)  (>20 min) Care Plan Oversight   (15-29 min)  ( ≥30 min) Provider signature (MD, DO,PNP, RN)

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43 Telephone Services 2008 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 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-30 minutes of medical discussion Mild Asthma exacerbation Assess, Treat, Follow up

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

45 Properly trained and equipped < 20% in this category need ER or
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 CPT Code:  99441 (5-10 min) 99442 (11-20 min) 99443 (>20

47 Asthma Action Plan The colors of the traffic light will help you use your asthma medicines Date of Discharge Next Doctor’s Appointment Date: Time: Doctor’s Name Doctor’s 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 Medicine How Much to Take When 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 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 minutes Breathing is hard and fast Ribs show Lips or fingernails are blue Trouble walking or talking 4 - 6 puffs of inhaler, or Give Albuterol treatment every 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 Do NOT wait! See your doctor within 3-5 days of an ER visit or hospitalization items that trigger your asthma and things that could make your asthma worse:Tobacco

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

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


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