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Case Study – La Familia Primary Care

Practice builds Chronic Care Management with MediTouch module and becomes business model for others

The Challenge

Physicians and staff at New Mexico’s La Familia Primary Care realized that they were already providing focused care and performing the duties outlined in the Chronic Care Management program for many of their patients with one or more chronic conditions. However, the practice was not providing this type of care in an organized fashion and they were doing so without the added revenue ($42 per 20 minutes of non-face-to-face care, per patient, per month) authorized by CMS for billing for CPT code 99490. As they began to adopt and build a Chronic Care Management program, “We asked ourselves, ‘What’s the best way to handle this?’” recalls Marcia Hefker, CFNP. When constructing a CCM program, coordinating efforts and establishing, implementing, revising, and monitoring comprehensive care plans can prove to be quite a feat – in addition to recruiting patients and keeping them engaged, which has proven to be one of the biggest challenges facing organizations trying to introduce chronic care management programs.

The Solution

The staff at La Familia made a concentrated effort to gain buy-in from the hundreds of patients they identified who would benefit from Chronic Care Management, and enlisted staff members and their MediTouch software to organize their efforts and customer service.  “We never felt overwhelmed because we have such huge confidence in our EMR. It’s just a matter of clicking on the ‘on’ button and using it,” says Hefker.

The Results

It took about two months for Hefker and the staff at La Familia to get 950 patients signed up. “We chose a personable approach,” Hefker says. They had their staff LPNs and RNs send each patient with multiple chronic conditions an informational letter about the program as well as calling them until they were able to speak to each patient live. Patients were given a chronic care management agreement to sign, and the practice then set up 1-800 number that gave their patients 24-7 access to their nursing staff.

They then set their organized plan into motion. Someone from the practice calls each patient monthly, and if a patient can’t be reached directly, he or she is encouraged to check their YourHealthFile patient portal for messages. Patients who don’t have access to a computer are asked to come in and the staff at La Familia assists them with a computer at the office. They also have nurses visit their homebound patients.

Hefker attests that their Chronic Care Management program has greatly improved their communication with their patients. “And it’s bringing preventative care to the forefront,” she says. “Patients are getting personalized, dedicated time and it’s helping us pull together a lot of loose ends. It’s allowing us to document a lot of information.” MediTouch’s CCM module provides a way for the La Familia staff to easily streamline each patient’s care plan, record all of their Chronic Care Management services, and bill for services per patient, per month. “The module that HealthFusion put together is great and very efficient. Allows nurses and staff to get in there and track every movement,” Hefker adds.

Hefker, the physicians and other staff members at La Familia are also finding that their patients are embracing CCM. “They really like it. They feel empowered that they’re one phone call away from speaking to a nurse in the office.” La Familia tasks one person to man the phone, and they make sure each patient is called back within 10 minutes. “We’re finding that it’s actually helping everybody else work more efficiently since many of our calls are no longer being routed through the front desk. The CCM module is going to decrease administrative time.”

In addition to the success La Familia found for their own practice, Founded Zmily Health Group, a turnkey solution to efficiently implement Medicare’s Chronic Care Management system. They are helping providers with their business models. “MediTouch is part of our package. It’s brilliant.”