In a continuation of the COVID-19 educational webinar series, Dr. John Findley, Medical Director of ACO Programs with Caravan Health, hosted a webinar to discuss protecting vulnerable patients with proactive outreach during the pandemic. Dr. Findley’s stated goal was to shine a light on the importance of active outreach to at-risk individuals and engage them in new care path options.

There is potential to make a positive impact on communities and by not acting proactively the circumstances could be dire. Opportunities exist well beyond what physicians and advanced practice providers can do which speak to the value-based model of nurse-led workplans. Nurse-led models are a critical ingredient to using telehealth, virtual care, and outreach effectively.

No action is not an option.

Key Steps:

  • Consider your surge capacity and prepare – reengineering care plans takes a team
  • Let patients know you are available and establish a clear, virtual pathway to meet their needs into the foreseeable future. This outreach will also help to maintain rapport.
  • Implement CPR:
    • Communicate & Connect with every vulnerable patient in your practice
    • Prepare your team with new roles, workflows, virtual care delivery models
    • Remotely serve & protect patients using telehealth and promote services to increase connectedness during social isolation
  • Schedule protected time for licensed staff – look at them as a revenue generator
Most importantly, without immediate access to patients, running a comprehensive review including a list of their active and ongoing conditions will help your staff formulate a plan of action to arrange continuing care throughout the year.


Questions & Answers:

Do you see Medicare waiving the requirement for the video component of the AWV? This is a barrier for many patients and a negative impact on our ability to move our numbers.
I’ve seen no guidance to suggest that that’s going to be happening. We are trying to advocate for the fact that telephone E/M visits, particularly for our RHC/FQHCs, is going to be critical to their success. Rural communities often have a higher percentage of individuals without access to video. We are trying to advocate for more telephone-only services, particularly for rural situations as many in these communities do not have access to video/wi-fi.
What do you think of cross training our physician staff to assist with a surge at the hospital?
Yes, absolutely consider your first order of business to make sure that in an event of a surge you are prepared. Many retired physicians and specialists are jumping into the line of fire to assist in COVID-19 coverage. Our goal today was to shine a light on the importance of the potential for an outpatient tsunami of untreated chronic disease and associated complications. A national dialogue has recently surfaced around “where have all the heart attacks gone? – where are all of the acute illnesses that are typically hospitalized?”. Many anticipate that chronic diseases if left untreated, will result in a surge of patients who come back into hospitals in the coming months. So, connecting with those at-risk individuals now is important.
What vitals are essential? What if they can only report their height and weight?
We recognize that many have voiced concern about the ability to capture vitals during the Annual Wellness Visit. It is apparent throughout the recent Interim Fee Schedule that CMS intended to make many services available to avoid unnecessary exposure to at-risk individuals. Good faith efforts to connect with and provide care to patients in the safety of their homes must be made. We recommend that you make a good faith effort to obtain any vitals that the patient can provide during these visits. It is also important to document that during this public health emergency this is what you were able to capture.  As long as you are making note of your efforts and what you could reasonably capture to guide care, we believe you are acting in good faith.
For the telehealth AWV, does the PCP have to join in on the same call or can he follow up later in the day?
I want to emphasize that telehealth requires a video component, so I am assuming that’s what you mean when you say, ‘call’. A provider may complete the telehealth component of these services “asynchronously” as long as it occurs on the same date of service. As an example – a nurse could complete their portion of the AWV intake in the morning and a billing provider could reconnect with the patient later in the day to review the personalized prevention plan, care plan as noting by nursing.
How do you do supervision in a telehealth visit?
We have received guidance that direct supervision can be provided remotely and that the billing provider does not need to be in the same physical space as the nursing staff. However, please note that, by definition, telehealth services must include a face-to-face by the billing provider. Many are confused by this.  Our recommendation is that the provider review the prevention plan, open quality metrics, and any pertinent changes noted in medication and diagnosis with the patient.  

What is the expiration date for temporary coverages of AWVs for telehealth?
Payment for telehealth is approved for the duration of the PHE, or through December 31, 2020, whichever comes first. If (when) the PHE continues beyond December 31, RHC/FQHC telehealth will receive new payment rates. In FFS, most guidance has been for the duration of the PHE.
Has CMS stated that audio only is acceptable under the waiver for all services?
Just to reiterate that so far, guidance states that for telehealth you must have audio-video capability. Telehealth cannot be performed by phone or telephone only.
What about the elderly or low-income patients that don’t have access to video?
We are advocating for a broader application for the telephone E/M visit recognizing that, as current industry data suggests – particularly in rural environments – up to 20 to 30% of patients may not have access to broadband internet and/or video platforms.

Just an anecdotal comment, I’ve heard some great stories of IT departments working to gather old iPads from their staff and wiping them clean and figuring out ways to get patients this technology. I think there are some creative ways to get some of this technology in front of patients and in my area some broadband companies are offering free service. However, we recognize that the telephone may be the only way we can connect which is the reason we really need to continue to push to make that more widely available in rural communities.
For an RN at an ACO who is providing education or medication management, can they bill for those services via telehealth?
No. Although staff can contribute to the telehealth service to get them set up online, think about it like a doctor’s office visit. The nurse would room the patient and assess, do a med review and could close the visit with some education but this is not billable time that can be counted towards telehealth. There are some assumptions built into the fee structure for that which assumes the nurse time in the setup and closing the visit. I encourage you to recognize that CCM is an extremely viable option and right now is the best way to maximize your RNs as highly licensed individuals who can provide these services, to enroll these patients in CCM.

The RN can continue to support them between video face-to-face time with their provider, continue with medication management, and treatment compliance. CCM is absolutely the best way to maximize their time and recognize that it’s not just the RN. Anyone doing education, including dietary education, your pharmacist working with medication management – licensed individuals - can bill for services via CCM and BHI where applicable.
So, we can proactively reach out to patients to let them know they are due for an AWV and schedule a telehealth visit? Can you solicit the interest of a patient? Is that acceptable to do for active outreach?
Yes, you can absolutely let a patient know that they’re due for this preventive service. Ultimately, the patient has the choice. In the context of the public health emergency we need to let them know that in order to protect them the primary reason for the outreach is to make sure they’re safe, that they are getting their needs met, and make sure they’re staying at home during these periods of social distancing. It is perfectly acceptable to do proactive outreach to let them know they’re eligible for the AWV and recommend this visit as an opportunity to establish a virtual care path during the PHE.

Again, the patient has to consent to the service. If they say no to the AWV, you just don’t want to lose sight of the fact that this is about connecting with vulnerable or at risk patients and establishing ongoing care management so although the AWV may not be their preferred solution or they may not be ready for that, please remember that you recommend appropriate follow up via a telehealth visit. Most of the individuals who you reach out to have chronic conditions and are in need of ongoing care and we need to establish a plan. So, if it’s not an AWV, maybe it’s CCM, if not CCM, it’s a telehealth visit and beyond. The outreach is what matters, the patient’s decision may vary.

In an AWV, how do you suggest the nurse handoff to the provider? Does it follow sequentially in time?
Those are the logistics you’ll have to work though. Some of that is contingent upon your telehealth platform. Zoom is one example that has a waiting room feature. If you have the capacity to have a waiting room feature, I suggest you try and keep those simultaneously tethered so that work stays and gets done. It makes more sense to me intuitively that you would try and complete that visit if possible. As for the earlier question, I think in terms of a provider finishing it at a later point on the same date of service I can comfortably say I think that would be ok.

There are some creative ways that nurses and physicians are working together via text, email and phone to make this as seamless as possible and to complete the visit in one session.
What about vital signs from patients and most recent previous office visits and noting the date on the vital signs when obtained?
It’s an interesting question for quality reporting – you could refer to the most recent office visit on record and I think that’s actually going to be the last blood pressure that would go towards our quality reporting recognizing that a patient can’t self-report manually obtained data for quality reporting. I would argue that if the patient has the ability to check their blood pressure you would want to check that at that moment in time. There are some measures that look for the most recent visit and some of them have look-back periods. For vital signs for hypertension, it might be possible to use the most recent blood pressure that you have on file.
Can the nurse do the first element of the AWV entirely by phone and then the physician actually complete that as a telehealth visit?
Yes. As long as the physician is doing the real time video component of the telehealth visit, this would be acceptable. The provider should review appropriate nurse screenings that are part of the AWV during this time


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