Bon Secours Next Generation Healthcare:
Chronic Care Management Requires Comprehensive Care Plan

A key component of chronic care management is a comprehensive plan of care—the 'refrigerator copy' patients can refer to, explains Robert Fortini, PNP, chief clinical officer for Bon Secours Medical Group (BSMG).

Today, using 'smart tools' built into its electronic medical record, Bon Secours nurse navigators document 12-point care plans for the 50 patients they have enrolled in Medicare's year-old Chronic Care Management (CCM) codes—a number Fortini expects will double this month.

The CCM assessment tool also captures frequently forgotten issues such as depression, pain and sleep problems that can derail care, Fortini said in a recent webinar, Physician Reimbursement in 2016: Workflow Optimization for Chronic Care Management and Advance Care Planning.

In case you missed this webinar, you still have a chance to watch this highly-rated program.

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Bon Secours' 70 nurse navigators, embedded in physician practices, also tap these point-and-click smart tools to document transitions of care for patients recently discharged from the hospital. This Transition of Care smart note tracks 17 different aspects of patient care, including risk of readmission and medication reconciliation, and includes a placeholder for an advance medical directive.

Similar tools are in use for Medicare's three types of wellness visits, he added.

"I have been in this business a long time, and the documentation that navigators produce using these workflows is extraordinary," Fortini noted. "This is purposeful design. It tells a story and you have something actionable at the conclusion of reading it."

The smart tools are but one aspect of Bon Secours' Next Generation Healthcare initiative, which Fortini defined as "population health meets total access." Next Generation Healthcare fortifies the team-based medical home foundation Bon Secours introduced six years ago with expanded care access and technology, among other components the organization leverages to improve clinical outcomes and value-based reimbursement.

In the Next Generation Healthcare model, he continued, the primary care physician is the quarterback of care. But the embedded nurse navigators do the "heavy lifting" of enrolling at-risk patients into care management, building comprehensive care plans, and scheduling Medicare beneficiaries for annual wellness visits.

Additionally, Bon Secours has broadened its menu of care access, offering employee clinics, fast care and urgent care sites, self-scheduling and virtual visits for primary care. Bon Secours expects to expand its virtual visits to specialist consultations, behavioral health and even case management, in which a nurse navigator can conduct real-time medication reconciliations with at-home patients, he said.

Currently, Bon Secours is building the advance care planning component of Next Generation Healthcare, training a portion of nurse navigators as facilitators in a Virginia advance care planning initiative called "Honoring Choices," with the goal of formalizing the placement of advance directives in patients' records.

Investing in the resources necessary to manage end-of-life effectively is a critical aspect of Bon Secours' strategic initiative, Fortini concluded. "Forty percent of Medicare spend occurs in the last two years of life, and the pain, suffering, and emotional angst that occurs for patients and their families is incredible."

You can "attend" this program right in your office and learn about Bon Secour's experience with CMS' chronic care management reimbursement and how they are leveraging this experience for advance care planning.

It's so convenient! Invite your staff members to watch the conference. We will send you a DVD or CD-ROM of the conference proceedings or a link to our web site with a username and password. You can log in and view the program right from your computer — any time of the day or night, whenever convenient for you and your colleagues — and benefit from the archived recording of the conference, including the Q&A period.

You'll get to listen to the question and answer session to hear how Bon Secours documents the 20-minute chronic care management consultation requirement; the staff skill sets needed for chronic care management, transitional care and advance care planning; how an end-of-the-year push drove impressive results in Bon Secours' rate of annual wellness visits for Medicare patients and billings for transitional care codes; factors that contribute to a patient being stratified at high-risk of readmission; components of the script that nurse navigators use to encourage patients to sign a consent form for chronic care management services; and lessons learned for physician practices contemplating embedded case managers or nurse navigators.

To register for the on-demand re-broadcast, download an .MP3 file or order the training DVD or CD-ROM of Physician Reimbursement in 2016: Workflow Optimization for Chronic Care Management and Advance Care Planning, please visit:

You may also be interested in these chronic care management resources: