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How to Improve Chronic Care Management and Insight into Remote Annual Wellness Visits

In this episode of Ask Dr. Mingle, Dr. Dan Mingle offers some advice to improve Chronic Care Management efforts and provides insight into how Annual Wellness Visits can be streamlined with the help of remote platforms.

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Question One: Remote Annual Wellness Visits

Roland asks: “Is it possible to do an Annual Wellness Visit (AWV) with telehealth platforms? Can they be done remotely?”
  • The answer, as is often the case, is yes and no.
  • The COVID-19 pandemic brought about a rule change that permits remote Annual Wellness Visits.
    • All AWVs require measurements of weight, BMI, and blood pressure. You can fulfill these requirements by having the patient do these measurements or bring them into the office for a brief visit.
  • When the pandemic rules end, we’ll likely have to return to in-person AWVs. But AWVs don’t have to be completely in-person: the process works extremely well as a combined remote and in-person workflow.
    • A patient at home can complete the Health Risk Assessment (HRA) portion of an AWV before coming into the office.
    • Ideally, a patient would have constant access to the HRA portion of an Annual Wellness Visit, so they can update the assessment as their health changes and receive automated, up-to-date recommendations with these changes.
  • But, at least once a year, it’s crucial that providers see patients face-to-face to review the HRA output, answer questions, address concerns, and understand their priorities and goals.
  • Annual Wellness Visits are a substantial part of a patient-centered approach to healthcare. While you may be unable to do the entire process remotely, you can use some remote touchpoints to streamline the process.

Question Two: How to Improve Chronic Care Management

Martha asks: “Do you have any advice for improving our Chronic Care Management efforts?”
  • Dr. Mingle starts his answer to this question by relating some experiences from his career as a primary care physician, highlighting that he’s seen many Chronic Care Management programs come and go. Dr. Mingle mentions that most of these programs have felt fragmented and redundant in his experience.
  • It makes sense that Primary Care providers should own care management. The education of primary care physicians puts them in a great position to do the work required, and their attitudes are typically more conducive to Chronic Care Management.
  • Historically, Dr. Mingle has seen that most Chronic Care Management programs focus on a single high-risk disease. But, to be truly valuable and helpful to all patients, Chronic Care Management systems should scale to the entire set of patient needs across your organization.
    • This is a little different for specialty providers. Specialties each own their management of a set of events – typically an episode or specific disease – and specialty care won’t be focused on comprehensive or holistic care management. For this reason, specialists will likely be more focused on Transitional Care Management – transitioning the patient from primary care into the consult/referral, specialty care, recovery, and transitioning back to primary care.
  • Dr. Mingle mentions that there are some heartening trends regarding Chronic Care Management:
    • The AMA has been creating a steady stream of new billable codes representing a broad spectrum of the Chronic Care Management continuum.
      • The bad news is that this introduces complexity and frustration for providers and patients, so you must understand the rules correctly for new Chronic Care Management codes.
    • The movement toward capitated care is another helpful trend. In this regard, providers get paid to provide the best possible care for patients instead of focusing on the number of visits or calls.
  • Finally, Dr. Mingle mentions that to improve Chronic Care Management, it is helpful to think of your primary care practice as a “health care help desk” to create a program that meets your patient’s needs for all conditions and concerns.

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