Implementing High Quality Telephone Care in Pediatric Practice

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 MembersJuly 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. 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. 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 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. 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 • 99441 5-10 minutes of medical discussion RVU: .36 • 99442 11-20 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 • 98966 5-10 minutes of medical discussion • 98967 11-20 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 anestablished 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 99441-99443 if reporting 99441-99443 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; • 99339 - 15-29 minutes • 99340 - >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 careHow 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 MembersJuly 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) 99340 – (>30 minutes)

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

33. Content of Asthma CPO • Expectations about asthma • “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 • ”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

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______

40. Coding Time Call Ended Call Duration  <5min  5-10 min 11-20 min >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)

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. 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. 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)