And, again, good morning, and welcome. Thrilled to have you with us today. So we've got, quite a full house, looks like, well over sixty people, so that's fantastic. We're talking a bit about oh, okay. We're getting some feedback. Hold on. And, of course, my headset's tangled. Give me one moment. I will try to adjust this. So, hopefully, this will be a little bit better. Can folks know let me know if the sound sounds if the audio sounds okay. Alright. Perfect. Alright. Thank you. So, anyway, welcome. We as I said, we have a full house, and we have over seventy people now. So very exciting Talking about care management, which is obviously a hot topic within the PCMH. It has, been an area of some challenge for folks. This is why we like to cover this on one of our office hours each year. So let's go along. And, first, there's a standard disclaimer that we have to, provide now, as part of, the contract into HRSA just showing that the the this is a a product of NCQA, although it was under contract, for HRSA for technical assistance. So to formally introduce myself, I'm Bill Tullock, director in our federal services center, and that's the part of our organization here at NCQA that handles our federal, contracts. We also have a state counterpart. And, of course, we are part of the, organization that handles all of our sort of our research as well. And so thrilled to be with you. We're gonna talk a little bit about the care management requirements in the program, talk a little bit about some challenges with some, examples, pulled from reality, pulled from actual care management, some care plans, and you can give your opinion on them, as we go through. And then, hopefully, if you've got some positive success stories that you can share either through the chat or through, going live, with us, on audio. So let's jump in and, the care management requirements. And I am happy to say that, or maybe maybe you you aren't happy. I don't know. But the this is one area where we didn't have significant changes for twenty twenty six. Now most of you know there was a significant update to the program. We retired, a few standards, few requirements. We also added some. You will note just as an aside in the in the standards manual, that the, numbering does not change in that. In other words, if it was, like, I think q I eighteen was pulled out. Q I nineteen will stay q I nineteen just because for the the purposes of our reviews, we need to have the standards stay the same if they're gonna continue year to year so that we can continue to give credit for those standards, both in both in, the original transforming surveys and any additional surveys that come in, any additional sites that come in for transforming. Although there is a note that reviewing and revising a care plan twice a year, between those reporting due dates for AR is is a bit of a change. So yes. But in terms of the number and type of requirements, we are in pretty much a similar place as we were, back, in twenty twenty five. Oops. And, of course, there are still eleven, requirements within care management, and those still include the the two competencies, basically having to identify patients who may benefit from care management and then monitor the percentage who actually are part of the care management program, and then, of course, also creating and, maintaining and managing those care plans. So you can see here the requirements in bold are those that are core. The rest are elective. And so, this is also the the one concept area where there's, only one one credit elective. Most electives are are worth two credits. And so that's also one of the reasons that we have the rule that you have to do all forty core requirements and then get twenty five elective credits in at least five out of the six concepts, and that's specifically done, because Centimeters has so many two credit electives. There was a concern that, if we, made it a well, a couple of them are now one credit. I'm I'm just I'm just cruising through them now. And in fact, we seem to have expanded number one credits. But, anyway, that was part of the thinking, back when we, originally created the the requirements for for scoring for PCMH. So just as an interesting aside there. So oops. And then in the, electives, of course, the only elective in the first competency is that you can use comprehensive risk assessment, versus, the sort of the more manual method in CMO one where you actually are, identifying key characteristics of patients that you think might benefit from care management and then finding patients that meet those characteristics. Of course, in, comprehensive risk assessment, you are assessing risk across your entire patient population and then choosing those at the top of the the risk, or the highest risk to, potentially put into care management. Although those, of course, are are typically done based on electronic algorithms, which may or may not be, how do I put this, as as high quality as they should be. So we know there have been some concerns that some of the the algorithms may use, for instance, past claims use, which may, in fact, be a detriment to patients who did not have coverage for a significant period in the past where they're, they wouldn't have filed any claims, and, therefore, they may look somewhat less challenging as a patient than they really are in reality. I also remember, at least one of our health centers that, had an HIV clinic, where they when they first moved to comprehensive risk assessment, they realized that the patients at the top of the risk were also those who had, had HIV the longest. They were some of the the the patients who had, experienced sort that miraculous benefit of the original protease inhibitors back in the nineties, and they realized that those patients having sort of gotten through that that kind of treatment where there was so much more complexity in the treatment regimens, that they really probably didn't need care management, that they were doing just fine if they had they were long term HIV patients without significant, health problems now that, they probably didn't need care management. So they did sort of override their, their algorithm a little bit there. And then, of course, in the actual, care plans themselves, we, do have I'll talk in just a second about sort of what we're expecting to see in care plans. And, again, you have to have the written care plan that is and I've actually pulled up the standards. I've got them on another screen here so I can oops. I did not mean to do that. I apologize. This is what happens when you when you put your cursor on the wrong screen. And and please note, we do expect you to review a care plan at least twice a year, but it should be you know, the sort of the expectation is that, it's reviewed and updated at what we call relevant visits. So I think part of the reason that we did say that the twice a year is the idea, is relevant visits should be probably more common than not. And so, relevant visits are those that address an aspect of care that could affect progress, towards meeting the goals. It's the actual language we have in the standards, or require modification of a goal. So either they've met a goal and you wanna you wanna extend it or you wanna change the goal because it's clear that that's maybe a little bit beyond other capabilities. And so just wanna point that out that that in terms of the alright. So we recently the question came in. We recently have used z code z codes to report, barriers and, HC report to show risk stratification. Should that have worked, we don't have an NCQA response yet. I don't know enough about the Z codes themselves to know if that's gonna work in terms of identifying barriers. I'm presuming that you have this out out as a question either as part of a of an actual review going on or as a question just to our policy department. So I'm gonna have to defer to their answer in their response. So can care plans be sent to patients via patient portal or MyChart and be counted as given to them? And I my answer my immediate answer is yes. I just wanna make sure. Yes. So, specifically, we say at least twice a year, the care plan is printed and given to the patient or made available electronically. So patient portals, MyCharts, those kinds of things would, would definitely qualify there as well. Yep. So, question also came in. As an FHIR, we have patients who come to us only once, and I'm assuming that's not just once per year. That's well, I'll answer this two ways. What are your recommendation with the two year sort of, every, twice a year requirement in terms of review? So if you have patients who only come in once at all and you you never see them again, do not count those patients as part of your your patient population. So when we, are writing our standards and, Deborah, I see your your hand up, so I'll I'll unmute you in just a second. We allow practices to define their own patient populations, and you can define that based on how frequently folks come in. So if someone's only coming in once or only coming in once a year, I think it would be realistic to say this this may not be somebody, that we want to, count sort of as a patient in our population. So they you they're sort of they're sort of a an aspect to care management that the the patient has to want to be care managed. They have to be agreed to be part of the program. So if someone's only coming in once a year, even if you're asking them to come in more, to me, that's someone who probably shouldn't be in the in the care management, really. Oh, okay, Deb. That was that was my fat finger. I don't have question. Okay. That's fine. No problem. I understand the whole process of of that. Another question that comes in, how about mailing it to a patient if they don't have access to the portal? Yes. Obviously, with HIPAA, protections in place, but mailing it would also work as well. And then if a patient declines a copy of the care plan, and it's documented that they didn't want a copy, you were going to print it out for them or you had to print it out for them and they declined it, yes, I do believe that counts as giving it. In other words, you've you've made it accessible to them in the same way that you may may make it accessible on a portal, and they never access the portal. That's up to them if they wanna access it. Also, I I also know that we have gotten the, advice from our legal counsel. I guess that's right way of putting that if a patient drops, you print the care plan out and they happen to drop it in the parking lot, that is not a HIPAA violation because you gave it to them. They are now in control of their own information, and you can, as a patient, share your information with anyone you want, whether, intentionally or not. So the only thing I was gonna also gonna add about the care plan, the care management competencies is in the care plans, we have included the, person centered outcomes as a new, set of, electives. We've done that over the last couple of years both to include, those person centered outcomes and then also to monitor those person centered outcomes. And those, of course, are still electives, in the system. Alright. So, a question from someone who's relatively new at this, and so I think you can all see this question because she did send it out to the in the chat to everyone. So looking at patients who have a lot of social determinants of health issues, if someone just needs assistance with transportation, then I don't don't bother doing a care plan. This is a good idea about how to go about choosing who's part of my patient panel. Certainly, I mean, we, in CMO one and let me I'm gonna scroll up CMO one on my own screen here just so I have it in front of me. When we're looking at who sort of is included in the care management, what we the minimum we require is that you look at three out of the five areas that are in CML one. So those are behavioral health conditions, patients who have high cost or high utilization patterns, those with poorly controlled or complex conditions, those with social determinants of health that may, require challenges, and those, who may be referred by other organizations. That is their insurer may have flagged something. The patient's family may be coming in and saying we need help, but they're they're not doing well. The practice staff may identify this is this patient on paper looks good, but in reality, you know, there's a train wreck going on, and we need to we need to step in. So, you pick sort of who what what qualifies, in each of those areas and then which patients. Sometimes it's patients that have at least one. Sometimes they have to have two of the of the the issues. So I think if it's just someone who needs assistance with something like transportation, probably, not necessary to include that, in your care management, population, someone like that. And so I think definitely, yes. But if anyone has other ideas, please feel free to send those to Cath, Katrina, excuse me, in the chat. So, can you share any, best practices for what, a patient, center patient friendly care plan should look like, for example, is expected to be more condensed or simplified version of the full plan? We're currently using, OCEAN Epic and working on making care plans more accessible by accommodating patient literacy levels and language preferences. So we'd love any guidance or examples you can share. I'm gonna show you a couple of care plans that we've pulled out of actual evidence, in just a a moment after we go through the slides. We don't have any sort of best practices. As an organization, we've always shied away from that because what we don't wanna happen is, us to come forward and say, okay. Here's a best practice, and then everyone says, well, this is what NCQA says you have to do. So what's gonna work for one practice is not gonna work for the other. So I would certainly throw that out to folks in the chat as well. I see Dawn is responding on the STOH, question. But I would think if there's other best practices on patient friendly care plans, please throw those in the chat as well. Yes. They can be condensed or simplified versions. We actually talk about using language that's different in the patient's care plan from the from the clinical staff. And that may just be to to make, the the, care plan a little bit more understandable, to the patient. It should I'll talk in just a bit about what the care plan should include. So the care plan for the patient should still have the same content, but, yes, it can be a a shortened version, or one that is, less complex in terms of language. How how can we show that we have provided a copy via MyChart? In general, does this, need to be documented that a copy was given? I don't know that you have to document that a copy was given if you're sending it out through MyChart or a patient portal. You should have some statistics, though, as to how many of those how many of those patients I think there, the report would be how many, patients have had care plans updated in that portal or by Charter or wherever. If you have a record of that, that would be what I would present as evidence, at that point. So, advisable for some of these electives, for instance, identifying barriers. So if we look at CMO seven, which is identifying barriers over time, and then addressing, those barriers if necessary, should those be within the written care plan or documented in another area of the chart like encounter notes? I would say and I'm gonna give you my favorite NCQA answer of all time. So it depends, mainly, because I think it's gonna depend on what you're talking about in terms of the elective. So if you're talking about a patient centered outcome, that should definitely be part of the care plan because that's an outcome. That's a goal you're focused on that the patient has defined but is still measurable and part of the care management. So the the classic experience is, you know, being able to exercise for a certain amount of time versus having, spirometry reading of x or or y if you're a COPD patient. So that's the kind of thing we that definitely should be included in the chart. But looking at something like c m eleven or c m o seven, we are identifying barriers. That very well could be in the encounter notes. But, presumably, that would either lead to, an update or a review of the care plan if there are barriers that that may need may mean that goals need to be changed. So I think you could pull out of both of those. I mean, if you're if you're looking at the actual file review methodology, which we talked about a couple of of office hours ago and that that recording should be up in the next couple of weeks. If you're looking at those, you're you're you're actually looking into charts for for the evidence that that something's been done. I would definitely wanna be able to identify where in those encounter notes you're you're taking the information that the barriers were assessed, and then updates were or weren't made to the care plan. Could can I review acceptable ways to show our provider may review the care plan? Certainly. We'll look at that in just a moment. Why are patient preferences and self management not combined in this? So includes self management, includes patient preferences of gold. They're slightly different, actually, two things that as we define them. So, again, I've got my standards open. I always refer back to the standards because I wanna make sure I'm answering correctly. So patient preferences and functional lifestyle goals for c m o six are typically looking at things that the patient may want to perform but could be at risk due to the condition or the treatment plan. CMO eight about self management is what the patient can do themselves. So for instance, trying to think about good. I'm I usually have used my father's health care in the past, to to come up with these examples. He passed two years ago, so it's a little harder these days. I gotta remember. But he was in care management for diabetes, for instance. So, the self management might be, making sure that he's he's testing his blood sugar and, and using the insulin appropriately. That would be the self management side of things. The patient preferences or, or functional goals there, in his case, might be, a desire to reduce the number, for instance, of instances where he has, awakened in the light and has to, you know, drink juice or whatever because he's he's going on a sugar crash. That could be a patient goal that is slightly different than the self management. So the the we we record the preferences and goals slightly differently because that's gonna factor into what the care plan is aiming to achieve. CMO eight is really about how you're gonna achieve that in in terms of the what the patient is managing themselves at home. So the the question is we have patients with behavioral health issues where they're, getting psychiatric consultation, and then they have a care plan for their comorbid medical conditions. Are we supposed to give them a care plan for their reported behavioral health condition, or are we good with the psychiatrist referral? So I'm gonna answer this two ways. The first is if you're thinking just about CML one and sort of meeting NCQA requirements, you don't have to include the behavioral health issues as part of your selection criteria as long as you have three of the other areas. So that's not a big deal. I think it's up to you as clinicians, as to how much you want to address behavioral health concerns if they're being treated by another provider, within the care management. And it may be as simple as making sure that they're continuing to get that, behavioral health care that's outside of your practice, and that may be the the goal you have in your care plan to address it, as part of their overall management, again, going back to that self management idea. But it's really up to you and and the the clinical, team that's working with the patient, and what the actual, issues are. So whether or how you wanna incorporate behavioral health concerns into a care plan. So we have a contract with a vendor to, augment our care management for Medicare patients to include the patients that they are managing in our care management to submit to NCQA even if they don't do not do it even if they do not necessarily do everything NCQA requires. Yes. You would still wanna include those. They're still part of your care management. It's just that you have vendor doing some of the work for you. So as long as you have access to their, evidence or if I don't know if if is has gotten, approved by NCQA yet for, prevalidation. If they were prevalidated, then you wouldn't have to include the evidence. If they're not prevalidated, then you would just have to be able to access whatever evidence of whatever they're doing for for your review. So the the question is you need to, for CMO one, you need to assess at least three categories for patients that could benefit from care management, but you have to provide care management to patients from all three categories. We would expect at least one patient of the thirty you're gonna pull for your file review, for instance, to be in each of the categories that you're you're assessing, particularly if you're only doing three. So if you're doing all five, then I might there might be like, particularly the referrals from outside organizations or or patients' families, that may be very rare to see. So you may not have anybody with that. But I think if you're if you're only doing three, I we would expect at least one of the patients to fall in each three, but not all of them. So and certainly, yes. For c m o two, when you're looking at the percentage, you can look at things like capacity and and resources. Hopefully, though, when you're when you're cutting patients down, out of from the care management program because you don't have the resources to help them, hopefully, you're not doing it based on, type of of need, but rather extent of need. You know, it's it's the more challenging, the more complex patients that you wanna care manage, however you define that. So, I think in general, yes, we would wanna we would expect if you're using three categories, unless you're in a very esoteric position. I'm specifically thinking of when we had the military, contract, for PCMH, and we had the, four, or the three. Excuse me. Well, guess, guard counts as well. The service academies where, Sorry. I'm saying Dawn was also responding to this. The service academies where they you know, to do care management, they would, they have sort of a young healthy population. And in their case, the patients that they'd be care managing were actually those who've been injured at the academy and had long term, injuries where sort of they they're owned by the academy from then onward. So that might be a a case where you might, be a little bit more esoteric. But, I think Dawn's right that having, patients are for for within each of the groups probably makes more sense. The sharing are already actually asked for from each of the the three categories, so that does make sense that they're they're expecting that at least one patient will be in there. Yep. So I'm reading the question now. So okay. So patients who are very complex, they may have SGOH behavioral health and other, other conditions. They don't really fit into this one bucket. That's fine. You would count them in each of the buckets they fit into, honestly. So I think, I think the use that flexibility to account for multiple categories. You can say, look. This patient fits all of these categories. This patient fits two of them when you're showing those examples to the reviewer. Absolutely. I would say multiple categories on that. Give yourself credit for all if if they're that challenging and that complex, then I think you really do wanna give yourself credit sort of for all all that you're doing there. Alright. So let's talk a little bit about that care plan content. So, obviously, we are looking for a problem list, and this is all from CMO four. There is a we're looking for that expected outcome or prognosis. There is the idea that patients should be have at least have the opportunity to graduate from care management. They may never actually do that because of challenges or barriers. Again, I'm thinking about my dad. Part of his care management was looking at physical problems he had from bad back, from years of manual labor, and his prognosis, the outcome that they were aiming for was him being able to to walk unaided or at least with only a cane. What they ended up with was him in assisted living because the the back treatment just didn't work the way that it was supposed to. And so, you may never reach that that sort of graduation point, but that's the idea. Those treatment goals, which, again, would include the person driven ones, the your medication management, activities, any sort of other services they may need. And that's their that's where transportation might come in for someone who has complex needs, medical needs, and behavioral needs and also has to have transportation help, then, accessing transportation might actually be part of the care plan in that case, to help them understand. And then practice to review, or schedule to review and revise the plan as needed. So the question came up, you know, sort of how do you document that a review has happened? And, obviously, in the old days, you know, back back when I was young, used to just initial a piece of paper, and that was the way you could demonstrate that something was reviewed. Now I think it would have to be alright. So Dawn is pointing out that, in terms of of, looking to make sure you're you're meeting the CMO one criteria, those patients that fit into multiple ones, you really should count them in one is what the reviewers So you we would still wanna be able to show patients fit into at least, one patient is at least in all those buckets. But, obviously, if somebody has multiple needs, you can put them into any bucket you you want. So and then I think you would look at it and say, where do you need categories at this point? You know? I don't think it's that's, such a horrible thing. And then, some concern that that goals must be person driven, not can be. Now it's very clear. I'm looking specifically at CMO four right now in the in the, in the standards themselves, and I just wanna see patient treatment goals. I mean, they're they're what we say is that the, patient treatment goals to meet the expected clinical outcome, for example, exercising three times a week, medication management, and schedule to review and revise the plan as needed, such as a date or cadence for all enrolled patients. I'm just, again, looking through this to see if there's any Deborah, I I don't I'm not reading this as, that that treatment goals must be person driven. Now the person driven goals we talked about in Centimeters ten and Centimeters eleven are very specific. I'm wondering if they're if the language that they're using is incorrect in what they're really thinking is person, the person centered care plan, that sort of thing. But even then, it's very clear that the person centered outcomes approach is, itself elective both to include them and to to monitor afterwards. So, that's something I'll have to bring back to the policy folks, I think. One thing I think that's important also is that reviewing and updating the care plan is not something that has to only be done by the physician. So whatever area you practice in, whatever your your, laws are as it were in terms of, what folks can do in terms of their licensure, we definitely would would, prefer or or we're agnostic, excuse me, as to who is actually responsible for reviewing and updating. So that's one of the things that that I think is important is that, it doesn't just have to be sort of the lead clinician or the physician, whoever that is on the on the care team. It might be a nurse or a PA who's who's working with the patient as well who has the ability to do that. And, again, somehow, electronically identifying, if not that, there was an update made. I don't know if you have, records as to, you know, sort of who saved the the care plan last, but also, who's accessing the care plan. If you have logs of those, those might be another way to show that that, they're being reviewed on specific dates with specific visits. And then in terms of accessibility of care plans, we are looking, so that sort of everybody, can access the care plan, on the care team, in parts so that they can continue to reinforce. One of the important aspects, of care management is that the the messages are reinforced because a lot of times, it takes patients some time to understand and really process what's being asked of them. And so being able to have those those reinforced across the the whole team is really important. Also, that means that that there may be other ways to identify those barriers, to, improvement. And then also that if if you can, ensure that care plans are accessible to outside providers, that's gonna give them a clear understanding of, patient needs and what you're managing, at your end. Okay. So we're gonna get kinda practical here. I'm going to stop sharing real quick and switch files. Whoops. K. I love using multiple screens because it's easier, but then you have multiple screens running and you're not sure which one you're on. Okay. So this is an activity that we use that we do in the training programs that we do with the regional training programs. And this is again, these are some care plans that we look at, that are based on real ones. So we've obviously updated these and and made sure that we're not violating HIPAA or confidentiality of any way. So we're gonna look at the the following ones and just sort of think about some of these questions, sort of what stands out to you. And not so much do you think this is a good or bad care plan, but, what what do you think you could add? Will will the care plan as it exists be useful? What could you add to make it more useful? Is this comprehensive, or would you include other things in your care plan? That sort of thing. And then what kind of feedback do you receive from patients regarding their care plan? Do they post it on the fridge, share it with their family and friends? Do they not review them? I remember my father with his diabetes. He had a big it was a legal sized pad that was sideways that where he could track all the different, readings and things that he was doing, including his blood pressure and things like that, for his self management. So he was very dutiful about filling those things out, when he had, the need. Alright. So here we have, Mickey Mouse who's not doing well. So we have uncontrolled hypertension, obesity in lower back plane, lower back pain. Excuse me. I always do that when I'm saying that that that term. So, Mickey wants to exercise to lose weight. So the goals are to walk for at least fifteen minutes three times a week, have his partner walk with him, and, swing arms while walking. The outcome is to lose four pounds. And then, medication management added one, tab in the morning of lis lisopril. I'm not even sure if that's a real drug. And then barriers, concerns, he lives in a high crime area, unsure how safe walking would be, recommending walking with a partner or driving to a nearby park, and then reviewing one month. Now I think we can all agree this is not a comprehensive care plan. So any any, thoughts you have, you can either, throw those in the chat. If you wanna raise your hand, I can unmute you, and we can talk about it. But in this case, it seems to me that they're only really addressing one of the issues here, which is obesity. And, obviously, that that's gonna factor into your hypertension and potentially even your lower back pain, but this doesn't really address these other areas. And it doesn't seem like there's a lot of, you know, sort of focusing on one activity. This doesn't seem like a comprehensive care plan to me. I don't know if you guys agree with that. Would certainly think that this might be an interesting aspect of a larger care plan that's gonna address all of these concerns. But even for obesity, I think you would also wanna look at diet, and and some other, issues there as well. So this seems like it's a it's a little, a light on the the details that we would wanna we would wanna see. Here's another one for mini mouse. Hopefully, this is, not the same. Yes. So and good thing to point out, that a full active med list is needed, versus referencing the chart. And then, we need that that second date when the plan was reviewed and updated. Absolutely. Yeah. Just saying you added a a drug. To to what? How many are they on now, and and where is that located? That might be an issue. Here's another, example. For mini mouse, we've got uncontrolled diabetes, sleep hype hypoventilation syndrome, history of pulmonary embolism. The goal here is to lower the AC from nine point one to eight point seven. Expressed outcome is lower AC. Continue with the same regimen on medication management, whatever that is, and then person centered outcome with stretch goals and realistic goals. I have a lot of thoughts on this one, honestly. That's not a person centered outcome. Person centered outcomes are not unless the person is a doctor who is also works with diabetes, patients, I don't think that this would really be a person centered outcome. Now, again, if Minnie is a doctor or a nurse and a clinician and and understands things from a clinical perspective, that might make sense. And that would be certainly be something I would wanna tell a reviewer if I were using this as an example. But for a typical layperson, even someone like me who works in health care, the the the person that are outcome should be something that's meaningful to the patient, and I don't think h b a one c really is. Although it's an important measure, certainly, to most folks. Also, just sort of having the the continue with same regimen unless, and, actually, I think it should be regimen, not regiment. If I if I'm getting my words correct here, I think we would wanna if not list the medicines that are are currently being used, the full medication list, at least have it attached to the care plan or otherwise accessible. So if you've got a a MyChart thing or a portal, having that medication be something that they can click into, would be, you know, would be better than than just sort of continue with with what's going on. And then, of course, that schedule for review of two months from now. This does seem like it's a and even those stretch goals don't seem that that stretch, honestly. Getting it down below eight point five, This could this is concerning to me in terms of a a care plan. Excuse me. Got a couple more examples that we just wanna run through. Obviously, you can see the theme. We have Donald Duck now. Problem is pharyngitis. Treatment goals and expected outcome are just to improve my health and improve health. Continue to take all medications, stop smoking, bury the goal, spouse spouse smokes, no self management plan, and scored four on the sleep lid impairment prom, which is patient report patient reported outcome measure, next visit to review care plan. So, the question became, you know, the the that providers are required to sign off on care plans. And, in short, yes, that there should be some indication that the that the care plan was signed off on, that someone has has physically reviewed it or actively reviewed it during a visit. So an during an audit practice was asked to show this, and that practice was able to electronically show it. Folks who don't have electronic options, what would you what would you include in terms of evidence of that review? The I presume here the electronic option was, again, who's accessing the care plan, who's actually updating it electronically, which would show you that it was it was obviously being looked at and updated. So I don't know if folks have another any other examples as to how you might be able to show that review has actually happened. And, Deborah, I see you have your hand up. Is that Bareal? I can unmute you, if you'd like. Alright. Oops. So, Deborah, you can there you go. You should be able to speak now. I do not have a question, Bill. Sorry. No problem. Playing with the mouse. Perfectly understandable. No problem. If a patient has multiple chronic conditions for which the provider needs to address a care plan, currently, we're providing more than one care plan to such patients. Are we supposed to merge all of the care plans together or make only one addressing all the conditions, or is providing, multiple care plans to a patient. Is that okay? Again, I think this is really up to you and the and the the care team. I think our vision, honestly, would be that oops. And, Christine, do you have your hand up as well? I can unmute you. There we go. So, Christine, I think I'm Yes. Okay. Go ahead. I wanted to say, because of the EHR system we have for proving that the care plan was reviewed by the physician or by the provider in that area, If the person has Medicare because there is a Medicare billing component specifically for care management, that is how we show that the provider reviewed it because part of the template requires that before the bill is submitted. Oh, fantastic. Okay. That's so that's that probably also goes to the Z codes that we're being asked about before. So, yeah, that would make sense in terms of the the ability to me. Oh oh, perfect. Thank you. Perfect. Yes. So that does make sense that that would be a way that you would be able to, to meet that requirement. Absolutely. Yep. Okay. So with the multiple chronic conditions, I think our vision is that there'd be one care plan, But I understand that they may that may not be doable, and it may be I think whatever's gonna work best for the patient is gonna be what you're gonna want to include. But when you're including that patient in a a sample or you're providing examples from that patient, I would include all three of them. I mean, honestly, if I'm a reviewer and I see that you have three care plans for the three different conditions, I think I might, be more more impressed. Yeah. So the question about Medicare care management program be used as one of three of the five factors. I don't think if you limit it just to Medicare patients, the the concern is that the concern is that you're not gonna include all the rest of your patients in the care plan process. So I don't think you could use the Medicare program as one of those the one of the three out of five for CMO one. And then reviewing it separately, sorry, to to review the care plan. So, again, electronically, if you can show that the the provider's accessing it and updating it, at the visit, that's gonna probably your best way of reviewing it. The old fashioned sign off or patient note, you know, marking in the the actual, notes for the visit, for instance, care plan was was reviewed, no changes needed, something like that, maybe also a way. But that's gonna have obviously, you have to be a proactive kind of documentation thing you have to work with your providers to be able to do. As I said, the old fashioned way, we just sign off on a piece of paper, but we don't have paper anymore. So that's, that probably is is out as an option. But, I think the electronic access, electronic updating, and or patient notes are gonna be your best bets to be able to show that. And other ideas from folks, if you can throw those in the chat, that would be great as well. So, again, this one, I think we have, again, a lot of, detail missing. Improved health is not a goal. The goals have to be measurable, or it's not a it's not an outcome or a goal. When when have you gotten to improve health? I have no idea what that even means. So, obviously, there are some concerns there. And then here we have, the another, our last sort of example where we've got lower back pains, sleep app lower back pain, sleep apnea, asthma. Yeah. So so care plan tasks the provider in their inbox to complete another is oh, that's an interesting way of of doing it as well. Thank you for that FAQ, Dawn. I'd I'm not, I haven't memorized all those, myself. So patient goals, walk around the block three times a week, lose twenty pounds by Christmas. That seems like it's, those are gonna be sort of far apart. Exercise instructions and activity log for self management tools, Asthma can act depending on weather. Here's the plan and and review. Again, I think we want more detail for most. Yeah. There's no med list on this one. And presumably, if you've got anxiety, asthma, you're probably on some medications. And if your asthma concerns are gonna be that they're gonna act up, you're obviously gonna wanna have a rescue inhaler, if it's acting up, certainly. So I think, yeah, there's there's a lot, that we would wanna add to these. So interesting, another, comment for our system. All patient goals regardless of provider type generate to the care plan. That's great. If you can, if you've got something where you can send that or where it's automatically updating, I think that's fantastic as well. Alright. So that's the just gonna stop sharing there real quick. Go back to our original slide presentation. I can get back there. Yep. So I don't know if folks have any, you sort of positive success stories they may want us, we've got about eight thirteen eight to thirteen minutes left in this hour. We usually try to end our meetings at five of, just to give folks a breather in between meetings. But I don't know if anyone has, either further questions. Please send those through. Happy to answer those. We have a lot of good questions on this on this program. Also, if you've got any success stories with care plan, particularly if you've got things that, have really helped motivate patients and get them help them to, graduate out of care management, that would be fantastic to hear as well. You can again throw those in the chat, or you can raise your hand, and I can unmute you. And, again, if you have continuing questions, I know this is an area that has been challenging for a lot of of practices. We saw a rise in denials on annual reporting the last couple of years because of care management, concerns, and so that's why we've we've included this, as one to address. But I also think that that we're aware that this is, an area that is is more resource intensive, and can be a challenge for particularly for smaller practices. K. And remember also that we say at least seventy five percent of patients for Centimeters o four and o five. I think it's both of them. Hold on. Let me just double check. Yes. Which means seventy five percent is the bare minimum. In other cases, we say more than, which means that, the the the measure actually has to be above what we give you. So just be very careful for those at least and more thans in the language as well. Right. So a little bit of of about the selection of patients for the review, the record review workbook, on how to to, to pull, patients. Okay. So our recommended method, I again, there is a file review management, office hours from February that we we should have the recording up very soon if it's on up already. But, the the easiest way is to pick patients is you pick a date and you go backwards. So the if you were to pick a patient sample today, today is March seventeenth. Oh, I should have said happy Saint Patrick's Day for those of you who, celebrate this while I'm in my green shirt. Mary Margaret, taught me to to embrace my Irish heritage. That was my late mother. But so we're on March seventeen. So the the way you would pick patients is you would go back thirty days. So we want you to have thirty days experience with the patient minimum. You can't get a care plan done with in less than thirty days. So we don't want you to pick a patient that you just identified for care management yesterday where you've done no work. That that's not fair to you. So, so you would go back thirty days from March seventeenth, which would get you to February fifteenth, if I'm doing my math correctly. And then you would basically say, from February fifteenth going backwards, what were the the, most recent thirty patients that we saw that are in care management, and that had a visit that was relevant for what they're being care managed for? So you would go back and you'd say, on February fifteenth, which patients did we see at this practice? How many of them were in care management? And then how many of them had a visit for care management and say there were eight of them? So those eight would be the first eight patients in year thirty. Then you go back to February well, fifteenth was actually that was a Sunday, so you you would have to go back to to February thirteenth on Friday to do that. Then you go back to February twelfth. How many patients did we see? Which patients? How many of them which of them are in care management? And which of them had a visit for care management? There's seven more. Well, there's your fifteen. There your first fifteen. You keep going backwards by day until you get to that thirty patients. So, basically, pick a date in the past, go backwards from that date until you pick the most recent thirty patients in order that you saw that are in care management and were in, their visit covered something that is, they're being care managed for. So if we see an example of acceptable, care care plan, we actually don't have any sort of, like, good examples to share with you today. Again, we sort of shy a little bit away from those, but something that something that we've been asked, for for a while. And I I definitely hear the the concerns about, you know, everyone struggling with care management and the resources, needed. And, yeah, some of the the reimbursement issues are there. Particularly, I know in some places, there's a real issue with comorbid behavioral and medical conditions where, technically, you can't bill for both of them on the same day at the same visit, that sort of thing. So there are definitely we understand there are huge challenges, and that's that's one of the reasons we're looking at these requirements. Absolutely. Okay. Well, I wanna thank you all for joining us, today. I think it's, we've had a very, active session. I wish I had sort of the all the answers for care management to give you that that would automatically, make all your care management, care plans work. But, unfortunately, if I had that kind of magic, I'd a consultant. I wouldn't be working at NCQA at this point. So we're using an EHR that stratifies patients into various risk levels by itself. Does that work for c m three? It it it certainly sounds like it should. So if you wanna know specifically that that, system, you may wanna put a question in to our policy department specifically. But, yes, that's the that's the kind of, comprehensive risk management that we're talking about in CMO three. Absolutely. So are are there additional resources or support available to help health centers strengthen their Centimeters given the challenges? In fact, we are looking at expanding our national trainings for this task order because we're getting a few, we're getting fewer transforming surveys than we expected. So I would expect we we may do a longer, training on this again, later on in the in the fiscal year. You could cover this topic every month, and I would attend. Thank you. Alright. Well, thank you all. I'm gonna end the session, now. I hope you all, at least hopefully learn something. Just to let you know, just looking at my calendar real quick. Where is my calendar? The next office hours will be the twenty sixth, and it's gonna be on the PCMH self assessment. We had to move that from February. So, and that's also at two o'clock in the afternoon. So, and, of course, if you are looking for support, we do have our community of, PCMH certified content experts, and they're available, on the web if you are looking for those. So Alright. Thank you all, and, have a great rest of your afternoon, and happy Saint Patrick's Day.