The importance of care plans
Even with billing for CCM on the upswing, however, Ballou-Nelson believes many practices remain hesitant to use the codes because they don’t know how to properly develop and implement patient care plans. To start with, she says, plans often lack input from the patients themselves.
“When I do plan audits, I often see no voice of the patient whatsoever,” she says. “There’s nothing about their goals, about what they think is important. I have to ask the provider, ‘where is the shared decision-making, the self-management piece? What exercises and activities are you giving them?’”
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After the plan is created, Ballou-Nelson says, the next step is to develop templates that can be entered into the practice’s electronic health record (EHR) covering the plan’s goals, such as treating depression or lowering A1C levels. That makes the plan accessible to everyone in the practice who interacts with the patient.
Ballou-Nelson also recommends developing fact sheets and questionnaires related to the care plan that patients can take home and work with. The latter, she says, might ask the patient to list all their medications related to a disease such as diabetes and what the medication does. It could also include questions such as, “How do you feel about having to take insulin and other medications for diabetes?” “What are the hardest parts about taking your medications?”
The goal, she explains, is “to give patients some investment in their care. Then when you make those follow-up calls or they come for a return visit, you can relate back to the activities you’ve given them, and you’ve got topics to discuss.”
Putting together this kind of care plan can appear overwhelming at first, Ballou-Nelson acknowledges, but adds that it gets easier as it becomes part of a practice’s culture. For some practices, she says, the process has become so ingrained that providers develop care plans for every patient that comes in, regardless of the number or severity of their conditions.