Key Takeaways
Explore this framework of change tool to define the organizational stages of change elements and the outcomes for each stage necessary to achieve Medicare reimbursement.
Use this resource to map the key decision points within each stage of change that lead to the desired outcomes.
An overarching goal of NCOA’s Center for Healthy Aging is to strengthen and expand integrated, sustainable evidence-based program networks. A key strategy to accomplish this goal is to support aging services, public health, and tribal organizations across the U.S. in their efforts to achieve Medicare reimbursement for chronic disease self-management education (CDSME) programs. To break down this complex process into manageable components, NCOA has adopted a framework of organizational change with specific steps or stages of organizational change that are necessary to achieve Medicare reimbursement. These organizational stages of change revolve around five core programmatic elements: program delivery or implementation, accreditation (DSMT only), clinical supervision, billing, and documentation and tracking.
NCOA’s framework of change was adapted from the framework or model of change found in the Community Toolbox, an online resource made available by the University of Kansas. That framework describes a pathway of activities to achieve outcomes designed to build healthy communities and create social change.
Purpose
This framework of change tool is one of many resources that NCOA has developed to support community-based organizations as they work toward becoming viable providers of CDSME programs that are recognized by health plans and health care providers and have value in the marketplace. There is a two-fold purpose: 1) to define the organizational stages of change elements and the outcomes for each stage necessary to achieve Medicare reimbursement and 2) to map the key decision points within each stage of change that lead to the desired outcomes. A list of resources from NCOA’s website and other reliable sources are included to provide valuable information that can help with the decision making process. The focus is on three specific Medicare Part B benefits that offer potential to incorporate CDSME programs as a component of the service: Diabetes Self-Management Training (DSMT), Health and Behavior Assessment and Intervention (HBAI), and Chronic Care Management (CCM).
Implementation or Program Delivery
| Outcomes | Key Decision Points | Resources |
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Implementation plan in place Necessary partnerships established to successfully implement the program and obtain referrals |
Which Medicare benefit will be the primary focus of your effort: DSMT, HBAI, or CCM | |
| Where the program will be implemented, initially and potential expansion plans | Program Planning | |
| Who the target audience will be | ||
| Determine the Leadership, staffing, and infrastructure (leaders, trainers, program coordinator, quality assurance coordinator, etc.) to implement the program | ||
| What partnerships need to be established to successfully implement the program AND to obtain referrals; Who your competitors and potential customers will be | ||
| How you will market your program to differentiate your services in the marketplace |
Developing Your Value Proposition |
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| Whether or not your organization will serve as the Medicare provider or partner with a Medicare provider (see also Billing below) |
Accreditation (Applies on to DSMT)
| Outcomes | Key Decision Points | Resources |
|
Policy and procedure manual developed Test class started Test class completed Accreditation application submitted to AADE/ADA National accreditation/recognition from AADE/ADA |
Will you apply for accreditation/recognition through AADE or ADA (Before you can bill Medicare, national accreditation/recognition by one of these two organizations is required. The 2017 National Standards for Diabetes SelfManagement Education and Support (DSMES) define quality, evidence-based DSMES services that are the basis for accreditation/recognition and meet or exceed Medicare regulations for DSMT.) | |
| Identify qualified personnel (registered dietitian – RD— and paraprofessionals) to implement DSMES services and a quality coordinator to oversee the program design, implementation, evaluation, and continuous quality improvement activities (Note - The RD can serve as the quality coordinator.) | ||
| Ensure that personnel meet the training requirements (i.e., 15 CEUs for the RD and 15 continuing education hours for paraprofessionals and non-clinical staff) as specified by AADE/ADA and written position descriptions and resumes are on file | ||
| Who you will involve as stakeholders, and what roles will they play to promote quality and improve utilization | ||
| What are the barriers to and the need for DSMES in the communities that you plan to serve; how will your program address the needs of the population (consider language, race, ethnicity, culture, income, education, literacy); and who will you serve | ||
| Select and document the curriculum that you will use – DSMP originally developed at Stanford University – and how that curriculum is flexible and will be individualized based on each participant’s needs (e.g., documentation of each participant’s weekly action planning/goal setting) | ||
| How you will provide ongoing support and education for each participant | ||
| How you will monitor, measure, and communicate progress of participants to providers | ||
| When and where your test class will be offered, and who will the target population be | ||
| Determine a primary site and any additional sites for offering DSMES |
Clinical Supervision
| Outcomes | Key Decision Points | Resources |
|
Licensed clinician(s) committed to provide the service NPI confirmed or obtained for each licensed clinician NPI for each licensed clinician linked to Provider Transaction Number (PTAN) of Medicare provider |
Decide how clinical supervision will be provided (i.e., existing staff, new position, partnership, or contractual arrangement) and how to locate a qualified clinician. (This will be specific to the Medicare benefit that is the focus of your effort) For DSMT, how you will locate an RD For HBAI, which clinical model to use: a licensed psychologist, nurse practitioner, or social worker (for Medicare Advantage only) For CCM, which provider(s) to target to provide supervision (e.g., individual practice(s) or a management services organization (MSO), or do you intend to serve as your own provider (If so, your organization must have a nurse practitioner or physician assistant) |
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| What is the cost of the clinician to your organization, e.g. what are the going rates in your area, how much will you pay, how much time is needed to carry out the oversight and supervision | Centers for Medicare and Medicaid Services (CMS) Learning Network: NPI: What You Need to Know | |
| What is your organizational process for negotiating with and obtaining a commitment from a qualified clinician to provide the service | ||
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Find out if clinician is registered with Medicare, i.e., has an NPI If yes, enroll the clinician’s NPI with the appropriate Medicare Part B provider of DSMT, HBAI, or CCM If no, register clinician for an NPI that is linked to the appropriate Medicare Part B provider |
Billing
| Outcomes | Key Decision Points | Resources |
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For organizations that decide to become a Medicare provider:
For organizations that do NOT plan to become a Medicare provider:
For all organizations:
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Weigh the risks and benefits of becoming a Medicare provider (Note - The Medicare provider is legally liable and must have appropriate liability insurance) | Considerations for Becoming a Medicare Provider |
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Determine whether your organization will become the Medicare provider or partner with an existing provider to offer the Medicare Part B service(s) If your organization will serve as the Medicare provider:
If your organization will partner with an existing Medicare Part B provider:
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Considerations for Becoming a Medicare Provider |
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Decide whether your organization will handle its own billing or outsource it to a third party billing entity If billing is outsourced:
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| Develop a billing process that meets HIPAA requirements and agree upon who will be responsible for what (Work with your interdepartmental clinical and administrative team to develop a step-by-step written process) | ||
| Determine which claims will be submitted initially | ||
| Develop a process to track and reconcile claims that have been filed | ||
| What quality assurance measures will you put in place to monitor the accuracy of billing |
Documentation & Tracking
| Outcomes | Key Decision Points | Resources |
| Documentation and tracking system established |
What will your process be for documenting clinical information, tracking data, and reconciling billing in compliance with HIPAA Will you use a paper-based system, an electronic platform, or a combination of both If you plan to use an electronic platform, how will you select a vendor or integrate with a health care provider’s electronic health record. The platform should meet meaningful use standards) |
Health IT Care Management System Vendor Selection Matrix |
| What will your quality assurance process be for monitoring service delivery and documentation |
This project was supported, in part by grant number 90CS0058, from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy.
