Integrating Chronic Care and Business Strategies in the Safety Net (Toolkit)

Stories from the Field

GreenField Health, Chuck Kilo, MD

GreenField Health is an independent, six-physician primary care group in Portland, Oregon. GreenField Health also provides teaching and consulting services focused on all aspects of ambulatory care performance improvement. We started clinical services in 2001 by creating a fully paperless clinic that was established on the principles of the Chronic Care Model. We continue this focus today as we're moving to establish our second clinic and to drive continuous performance improvement in our clinical work. GreenField Health has a fully integrated electronic health record with a robust registry available to all clinicians. Our electronic health record and our registry provide:

  1. Patient-specific reminders of needed care at the time of visits.
  2. Lists of patients due for services
  3. Aggregate population-based performance data.

Our secure messaging system allow patients to connect to us electronically to provide updates on their care such as glucose levels in diabetic patients or weights in those with congestive heart failure. Secure messaging allows us to give patients rapid coaching and support for self-management, as well as timely lab results with instructions.

Specific benefits of the chronic care model to our clinic include:

  • Positioning our Group to excel at pay-for-performance, which is on the horizon in our state, Oregon.
  • Allowing us to Bill evaluation and management (E&M) code 99214 for nearly all of our visits for those with chronic conditions.
  • Supporting the Ability to Provide group visits at an E&M code 99213 or 99214.
  • Facilitating Payments of $30 to 40 per e-visit, so vital in our efforts to engage patients in relationship-based care, which we also worked with our insurers to establish.
  • Enabling Grant Funding of more than $75,000 in 2007 as we help others in our State to implement the Chronic Care Model. 

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Point-of-Care Hemoglobin A1c Testing at the Medical College of Wisconsin, Jaishree Hariharan, MD

At the Medical College of Wisconsin (MCW), the Primary Care Clinic partnered with the endocrinologists to test a reliable, easy, and effective point-of-care A1c test. Point-of-care A1c testing allows the physician or nurse practitioner to administer and receive results of the test at the time of the appointment—facilitating face-to-face information sharing, immediate decision making with patients, and better glycemic control.

MCW tested the DCA 2000, which requires a finger stick, analyses the sample, and provides the results in 6 minutes. After MCW tested and confirmed the reliability of the DCA 2000 in fall 2005, one medical assistant was trained on its use. It was piloted with one physician starting in November of 2005. By April 2006, all medical assistants were trained on its use and it spread to all the clinic physicians. The standardized lab testing was also available.

A total of 330 tests were performed over one year at the Internal Medicine Clinic in MCW. Approximately half the tests were ordered by the resident physician during their clinic sessions. The clinic has more than 800 diabetic patients. The impact of the point-of-care testing includes better diabetes control, improved patient care, and financial benefits. Specifically, the test:

  • Allows for Immediate decision making at the time of the visit.
  • Enables Physician to show patients a snapshot of their control over time, to help engage them in self-management.
  • Benefits Resident Physicians who are there only part time and decreases their paperwork.
  • ADDS VALUE for patients who cannot obtain standardized laboratory tests due to financial or transportation issues. The test is much more convenient and provides immediate answers.
  • Enhances Finances. The Centers for Medicare and Medicaid Services (CMS) increased payment for point-of-care A1c testing in 2007. 

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CareSouth Carolina Integration of Behavioral Health Services, Liz Kershner, MSW, LISW

Fifteen years ago, CareSouth Carolina ended the fragmentation between medical and mental health services by hiring clinical social workers to assist medical providers with the care and treatment of primary care patients with mental health needs.

Through our initial participation in the Health Disparities Collaborative for depression and implementation of the Chronic Care Model in 2000, our care teams:

  • Implemented evidence-based guidelines for the treatment of depression in primary care.
  • Used the Patient Electronic Care System (PECS), a clinical information system provided by the Bureau of Primary Health Care, to track the depression outcomes of all patients.
  • Screened all new adult and adolescent patients for depression with the PHQ-9, an evidenced-based, self-administered depression screening tool designed for use in primary care. All patients are also assessed for depression at their annual visits.
  • Monitored patients diagnosed with depression using depression care management guidelines. The PHQ-9 is the tool used at CareSouth Carolina to track outcomes and response to treatment.

Quality of Care

Currently, 47 percent of all CareSouth Carolina patients with major depression are achieving at least a 50 percent improvement in their depression outcomes within 4 months of treatment, as tracked by PHQ-9 score updates.

An additional benefit of onsite integration is the ability of the primary care provider to introduce the patient in need of mental health care to the behavioral health care provider by way of the "warm handoff." This promotes trust between patients and providers and coordinated care plans between providers.

Financial Impact

Primary care providers also appreciate the immediate availability of onsite behavioral health providers to assist with complex mental health cases, thus allowing them to maintain the quick pace of a primary care practice.

The clinical social workers at CareSouth Carolina have been credentialed with all major private insurance carriers as well as Medicaid and Medicare. Therefore, same-day reimbursement is possible for patients receiving both physical and mental health treatment at a CareSouth Carolina facility. The clinical social workers have also been added to local employee assistance programs. In addition, they provide mental health treatment in juvenile and long-term care facilities, which reimburse at least $65 per mental health session. 

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Economic Impact of Chronic Care Model Implementation at Mercy Clinics, David Swieskowski, MD

Mercy Clinics, a network of outpatient clinics in Des Moines, Iowa, began implementing a Chronic Care Model for diabetes care in two clinics in 2002. A disease registry was used to track all patients and a quarter-time care coach was identified in each clinic. In addition to improving the quality of care for diabetic and hypertensive patients, Mercy has also improved its financial position.

Because of prework done by the care coaches, use of standing orders, and use of a diabetes office visit form, providers were able to bill a higher level of service without requiring more provider time. An analysis of diabetes visit E&M coding for 2003 to 2005 showed that E&M level 4 visits went from 35 percent to 74 percent of the billings. The impact was to increase the average net revenue from diabetes visits by $12.29.

In addition to the increased E&M coding revenue, Mercy Clinics is seeing other financial benefits from Chronic Care Model implementation:

  • Increased Lab Revenue. Systemwide urine microalbumin testing went from essentially 0 to 10,868 tests per year. The Medicare profit was $8 per test, yielding about $87,000 profit per year.
  • Profitable Group Visits. Revenues exceeded expenses by a large margin.
  • Reduced Transcription and Filing Costs. The diabetes office visit form requires little or no dictation, saving physician time and transcription cost.
  • Increased Reimbursement for Patient Education. Mercy negotiated a payment of $54 for patient education with their largest insurer.
  • Pay-For-Performance Bonuses. Mercy has completed the first year of a pay-for-performance project and has received the maximum payment for all 25 providers involved for a total of $353,000.
  • New Grants. Mercy has received more than $170,000 in grant funding to further this initiative. 

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Reduced Hospitalizations in the Univera System

Univera's initial foray into disease management using the Chronic Care Model began in 1999 with congestive heart failure, a condition responsible for a significant portion of overall health care costs in the United States. According to Peggy Calogero, R.N., Manager for Univera's Chronic Illness Program, costs for congestive heart failure are increasing for a variety of reasons including lack of coordination in the delivery of care and wide variation in the application of care.

By the time Univera completed the Chronic Disease Collaborative, about 100 patients were participating in the program. Univera saw a reduction in hospital admission rates for heart failure. "Even with the increase in pharmacy costs, savings in hospitalization alone still created overall savings," Calogero says.

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Page last reviewed October 2014
Page originally created August 2008
Internet Citation: Stories from the Field. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD.