Overview

Establishing a protocol and workflow to capture value for the Federally Qualified Health Center by billing for nurse-led education visits

Organization Name

Mary’s Center

Organization Type

• Community health center
• Community outpatient clinic

Local/Organizational Context

• Mary’s Center, founded in 1988, is a Community Health Center that provides health care, family literacy and social services to individuals whose needs too often go unmet by the public and private systems.
• Mary’s Center uses a holistic, multipronged approach to help each participant access individualized services that set them on the path toward good health, stable families, and economic independence.
• The Center offers high-quality, professional care in a safe and trusting environment to residents from the entire DC metropolitan region, including individuals from nearly 50 countries, through 8 locations.
• Mary’s Center delivers care according to the Social Change Model with health care (including dental and behavioral health), social services, and education (through a public charter school) all under one roof.
• The organization had been specifically interested in ways to improve care coordination.
• The leadership team was specifically interested in developing a workflow integrating documentation and billing for nurse education and nurse care coordination visits which can take nurses up to an hour of patient care time.
• Before this intervention, the nurses at Mary’s Center had only been able to bill for influenza vaccine administration visits.
• This intervention was prompted by new nursing leadership.
  • The organization had been investing in a nursing administration leadership team and identified the budget as a priority area for improvement.
  • Dara Koppelman became Chief Nursing Officer after having been a nurse manager and she was very familiar with the role that the nurses at Mary’s Center had on-the-ground.

Patient Population Served and Payor Information

• Pediatric, adults, prenatal, women’s health
• 70% Spanish speaking
• Largely immigrant patient population from hundreds of different countries
• Majority of patients have household incomes under federal poverty level
• Payor mix includes roughly 25% uninsured, 15% safety net insurance, 50% Medicaid, and 10% mix of commercial insurances and Medicare.

Leadership

• Dara Koppelman, Chief Nursing Officer
• Ingrid Andersson, Director of Nursing and Education
• Julien Guttman, Director of Clinical Services
• Mary’s Center Nursing Team
• Mary’s Center Billing Department
• Mary’s Center Outcomes Team

Funding

• Grant funding supports some of nurses’ work.

Research + Planning

• Koppelman reached out to nursing administrator contacts at other FQHCs but found that none of them had advanced knowledge of this subject.
• Mary’s Center Billing Department identified 99211 billing code and provided literature to leadership team and Koppelman collaborated to produce an internal document on billable visits.
• Koppelman reached out to Washington DC Primary Care Association, of which all area FQHCs are members, and started meeting as an informal nursing peer-led group to discuss and share best practices.

Tools or Products Developed

• Internal billable visit type document
• Internal nurse handbook (“cheat sheet”)
• EMR-based nurse progress note templates with checklist to guide nurses through gathering necessary documentation for nurse billable visit
• New EMR-based nurse progress notes audit which could prompt nurses to complete billing documentation as necessary

Training

• All-Nursing meetings occur quarterly.
• In standing bi-weekly nursing leadership meetings, Koppelman, Andersson, and Guttman would work closely with nurse managers and train them on the process, which took on average half an hour.
• Directors of Nursing would also work with their direct reports in more detail as needed.
• The nurse managers would then review it with nursing staff in more detail.
• Training was also built into new nursing staff onboarding process, and new nursing staff would be trained on the job as they shadowed experienced nurses for one month

Tech Involved

• eClinicalWorks

Team Members Involved

• MAs
• NPs
• Physicians
• RNs

Workflow Steps

• Scheduling: Nurses have their own patient visit schedules.
  • Nurses handle both previously scheduled patient visits as well as same-day visits for which they will get a warm hand-off from the provider or Medical Assistant.
  • Most previously scheduled nurse visits are billable, but same-day visits are not.
• Patient Education: Once a patient arrives, a nurse provides patient education for 15 minutes to one hour depending on the patient’s needs and their language skills and health literacy.
• Documentation:
  • Nurses write a progress note and use an EMR-integrated checklist to ensure they have the proper documentation and then the note is forwarded to a physician, NP, or midwife to sign off, who then locks the note.
  • The completed progress note is then sent to the Billing Department, which reviews it and attached billing codes.
    • If the note is missing documentation, the Billing Department forwards the note to Koppelman with an explanation of what the note is missing.
  • Once the Billing Department review is complete, the Billing Department sends the claim out to the payor for reimbursement.
  • The outcomes team provides weekly reports of unlocked notes.  Koppelman informs nurses of missing elements of documentation needed on a weekly basis.

Budget

• $0-500

Budget Details

Not distinct from routine operational costs for nursing.

Where We Are

This intervention started in 2014 and is currently ongoing.

Outcomes

Regional recognition

• Mary’s Center received the 2017 and 2018 HRSA Health Quality Leader Award which Koppelman attributes to the increased quality of care that patients receive at Mary’s Center due to its emphasis on nurse education and care coordination initiatives.

Increased revenue

• Nurse billable visits generated ~$80,000 in revenue in 2017 or about the equivalent of 1 FTE nurse with benefits.  The revenue has steadily increased year over year.

Increased access

• Number of nurse visits / nurse has increased and number of nurses on staff have increased.

Creation of new role

• This process led to creation of a Clinical Nurse Coordinator role whose primary function is to perform patient education and care coordination.

Employee satisfaction

• Employee satisfaction scores have remained the same.

• Nurses appreciate organizational emphasis on patient education.

Unique Challenges

Difficulty accessing resources

• Information about nurse billable visit workflows and reimbursement success rates was not readily available from current sources or FQHC contacts, and the leadership team felt they had to test it themselves.

Variability of nurse visit reimbursement

• Reimbursement rates for nurse visits are highly variable depending on the payor and geography (i.e. Maryland payors are not reimbursing for nurse billable visits, while most Washington, DC payors are)