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Medicare Visit Workflows @ Brookside Community Health Center

Keywords: Medicare, Annual Visit

Overview

Development of a team-based workflow for Medicare wellness visits to increase access to the service and bill appropriately while allowing all clinicians to practice at the top of their licenses

Innovator

Cynthia So-Armah MD

Editor

Meg Krasne MD MPH

Location

Brookside Community Health Center, Boston MA

Organizational Context

  • Brookside Community Health Center has recently become a patient-centered medical home. It has been experiencing a movement towards increased efficiency and better billing practices.
  • Department staff works in teams of primary care providers, registered nurses (RNs), licensed practical nurses (LPNs), Medical Assistants (MAs), and practice assistants.

Population Served

  • Patient population is largely Spanish speaking. Many patients are first and second generation immigrants from Dominican Republic, Puerto Rico, and Central/South America. 
  • A large percentage of patients are on MassHealth insurance.

Project Leadership

  • The organization brought on a new medical director with previous experience at a clinic that used team-based workflows. 
  • The medical director identified an opportunity in the Adult Medicine Department to develop a similar workflow.

Funding

  • Lead physician for QI and an adult NP approached Partners to apply for maintenance of certification for the project in August 2016.

Project Research & Planning

  • The team brainstormed potential workflows, drawing from other clinics’ efforts and Medicare wellness visit requirements. 

Project Tools & Components

Key components of the intervention include:

  • Workflows for both providers and medical assistants
  • An EMR note template that automatically pulls in components of required screenings
  • A paper rooming sheet including vitals and positive screening tests that MAs fill out and give to providers before they walk in the patient room.
These components were tested in clinic starting in March 2017 and tweaked as needed.

Training

  • Around the time the above components became available, the first two MAs received training in the workflow, including a 30-minute MA meeting to review the workflow using training documents, a 15-minute session configuring the MA’s EMR to create bulk orders and notes for the visits, and another 30-45 minutes of continued learning during sessions as the MAs started to perform MWVs and become more comfortable with them. These MAs then participated in training other MAs. 
  • MDs also received a 30-minute training in the workflow during an MD/NP chart review, with a 15-minute follow-up at a subsequent chart review.

Tech Involved

Epic

Team Members

  • Physicians
  • MAs

Daily Workflow Steps

  • Practice assistants schedule only one Medicare wellness visit per session per provider, as these visits take a lot of time for the medical assistants.
  • In pre-clinic huddle, providers sometimes provide notes to the MA regarding specific screenings for the Medicare wellness visit patient. 
  • When the patient arrives at clinic, the MA rooms the patient, takes vitals (height, weight, BP, temp, HR, oxygen saturation) performs requisite screening tests (hearing and vision screens, falls screen including Get up and Go testing, PHQ-2), designates visit diagnoses, pends referrals and other orders, and inputs after-visit summaries into the EMR. 
  • If screening tests are positive, the MA pends referral to the appropriate specialty (audiologist for positive hearing screen, ophthalmologist for positive vision screen, and physical therapist for positive falls screen) or follow-up testing (PHQ-9, an extended questionnaire, for positive PHQ-2).  
  • Then, the provider sees the patient, confirms the diagnoses, screening tests, and orders, signs orders that were pended, and completes the visit. 

Budget

$0

  • The intervention was free to implement, besides the opportunity cost of time taken from other things (ex. training time, IT setup of EMR).  
  • The visits are scheduled within the MD/NP's existing schedule, fitting into time allotted for standard patient visits.
  • The project was spearheaded by the Lead Physician in Quality Improvement at Brookside Community Health Center, who is 12.5% FTE for QI.

Status

The intervention is currently ongoing

Outcomes

  • The key outcome is a process measure: # of patients >65 years old with a charge for a Medicare wellness visit in the past year / total # of patients >65 years old with Medicare who have a primary care provider at Brookside Community Health Center
    • Analysis of this measure has shown that the percentage of eligible patients receiving MWVs in the prior year increased from 3.5% in February 2017 (prior to implementation) to 21.8% in August 2017.

Future Outcomes

  • While it is thought that the project has led to increased revenue generation via increased numbers of MWVs (which are reimbursed at a higher rate than the alternative, annual physical, which can no longer be charged for Medicare patients) and has saved physicians time, no data has been collected on these metrics.

Benefits

  • The program has led to improvement in the measured outcome (percentage of eligible patients receiving MWVs).
  • The workflow has improved team communication and has empowered MAs to do more in their role. 

Unique Challenges

  • Scheduling was initially a challenge. Medicare Wellness Visits can take some time, and too many patients were being scheduled for these visits in a single clinic session. 
  • Practice assistants started scheduling at most one Medicare wellness visit per clinic session for each physician, which helped this issue.

Personnel Challenges

  • There was initially some pushback from providers, who have many responsibilities and did not necessarily want another protocol to follow. 
  • During the initial MD training, it was stressed that the workflow would ultimately save MD/NPs time, as much of the work for the visit would be done by the MA before the provider even met with the patient. 
  • Also, checking in with providers as the project rolled out, and troubleshooting problems as they came up in clinic in real-time, helped to reduce overall frustrations around implementation of the workflow.
  • Staff turnover (a few MAs several times a year) requires ongoing training of new staff in the workflow.

Glossary

Medicare Wellness Visits: In addition to covering an initial preventive visit upon enrollment in Medicare, Medicare Part B covers a yearly wellness visit designed to prevent disease and disability by assessing the patient’s health and risk for disease. According to Medicare.gov, a yearly wellness visit should include the following components:

  • A review of your medical and family history
  • Developing or updating a list of current providers and prescriptions
  • Height, weight, blood pressure, and other routine measurements
  • Detection of any cognitive impairment
  • Personalized health advice
  • A list of risk factors and treatment options for you
  • A screening schedule (like a checklist) for appropriate preventive services. 
  • Advance care planning
  • https://www.medicare.gov/coverage/preventive-visit-and-yearly-wellness-exams.html 

Maintenance of Certification (MOC): a process in which physicians can engage through their medical specialty board meant to allow physicians to stay current in the medical knowledge they use to treat patients. It requires participation in knowledge-acquiring activities and assessments.
http://www.nejm.org/doi/full/10.1056/NEJMp1407422
http://www.abim.org/maintenance-of-certification/default.aspx

Patient Health Questionnaire-2 (PHQ-2): first-step depression screen using 2 questions. Patients are asked how often they are bothered by the following two problems over the past 2 weeks: having little interest or pleasure in doing things and feeling down, depressed or hopeless. They rank each question from 0 (none of the time) to 3 (nearly everyday), and their rankings are summed to create a total score out of 6. A PHQ-2 cutoff score of 3 is typically used. A positive screen prompts a more extensive screening using PHQ-9. http://www.cqaimh.org/pdf/tool_phq2.pdf

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