On Florida’s Emerald Coast, Progressive Chronic Care Management Breaks Through

May 11, 2023
The leaders at White-Wilson Medical Center, a multispecialty medical group on Florida’s Emerald Coast, have been working at optimizing chronic care management for Medicare patients

A wide range of chronic care management models are emerging across the U.S., as the leaders of patient care organizations of all types, including multispecialty medical groups and medical groups affiliated with integrated health systems, explore the possibilities inherent in improving care management for patients with chronic illnesses.

In the northwest corner of Florida, leaders at Fort Walton Beach-based White-Wilson Medical Center are working to optimize chronic care, and have been partnering with the Carrollton, Georgia-based CareTrack Health, a company that helps medical groups optimize their chronic care management. White-Wilson Medical Center is a multispecialty group encompassing 50 physicians and 45 allied health professionals working in eight clinic locations located in Fort Walton Beach, Crestview, DeFuniak Springs, Destin, Navarre, and Niceville, along what’s known as Florida’s Emerald Coast, just east of Pensacola in the Panhandle, the far-northwest corner of Florida. The clinicians at White-Wilson log 270,000 patient visits a year.

The White-Wilson leaders have been working with the professionals at CareTrack for eight years now, since 2015, and CareTrack’s team is fully enmeshed in White-Wilson’s clinical operations. As CareTrack’s website explains, “CareTrack provides the ability for medical practices to identify and provide their most at-need critically and chronically ill patients with a tailored, systematic care plan.  The adherence system right-sizes patient support outside of the office, dramatically improving clinical outcomes, including better preventive service utilization, improved quality measures, and increased per-patient profitability.”

And CareTrack’s CEO, Andrew Mills, explains that “CareTrack is a company that provides out-of-office care coordination for ambulatory medical practices. We’re a tech-enabled service that utilizes nurses and medical assistants, using technology, to keep patients adherent, and we call patients and make sure they’re following a technology that keeps them in adherence. We’re at 65 employees, and we have 75,000 Medicare patients in our network, provide service to 15,000 patients a month,” he adds, noting that his professionals help medical groups work either in the traditional fee-for-service Medicare area or in the Medicare Advantage program. CareTrack’s operating model is set up so that “We go at risk with the medical practice,” he explains. “We’ll do work that can’t be billed.”

The partnering described here is taking place in the context of the Chronic Care Management and Connected Care campaign at the Centers for Medicare and Medicaid Services (CMS). As the program’s page on the CMS website explains, “An estimated 117 million adults have one or more chronic health conditions, and one in four adults have two or more chronic health conditions. Through the Connected Care campaign, the CMS Office of Minority Health and the Federal Office of Rural Health Policy at the Health Resources & Services Administration will raise awareness of the benefits of CCM for patients with multiple chronic conditions and provide health care professionals with resources to implement CCM.”

And, the program’s page explains, “CCM is care coordination services done outside of the regular office visit for patients with two or more chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. These services are typically not face-to-face and allow eligible practitioners to bill for at least 20 minutes or more of care coordination services per month. With millions of Americans living with a chronic health condition, your support is critical to raising awareness about the benefits of CCM services. By offering CCM services, health care professionals can deliver the coordinated care their patients need and help patients stay on track by getting support between visits,” CMS explains. And, in that context, the agency explains, “Physicians and the following health care professionals can bill for CCM services: physician assistants, clinical nurse specialists, nurse practitioners, and certified nurse midwives. Federally Qualified Health Centers, Rural Health Clinics, and Critical Access Hospitals can also bill for CCM services. Only one practitioner per patient may be paid for CCM services for a given calendar month.”

Healthcare Innovation Editor-in-Chief spoke recently with Mark Wiacek, White-Wilson Medical Center’s COO, and with Vergil Brown, M.D., the group’s medical director, who continues to practice as an internal medicine physician, regarding their chronic care management work, including their partnership with the professionals at CareTrack. Below are excerpts from that interview.

What made you decide to work with the professionals at Care Track?

Mark Wiacek: We had already had a relationship with them for several years; they came over from Greenway, our legacy EMR product. We had worked with them around optimization and quality initiatives. And then Andrew Mills and Andrew Skinner and Derek Skinner spun out CareTrack to focus on chronic care management. We already knew each other well.

Where were you at early on in your journey around chronic care management?

Vergil Brown, M.D.: Basically, we understood that this [the Chronic Care Management program, as explained above] was an obvious way to improve quality of care to our patients, and we were trying to pull together our resources internally. We had several dedicated physicians who wanted to make it happen. The requirements from CMS are onerous, and include having 24/7 nurse on-call care, as well as the documentation requirements. We knew we wanted to do it, and could see the benefits, but didn’t have the internal resources to pull it off.

Medicare created this program as a means to keep patients healthier and reduce Medicare expenditures. Hospitalizations and ED visits. The average cost of an ER visit in this country, even without medications and studies, is $2,000; and it’s $10,000 when you include those other services. So Medicare wisely said, if we can identify those patients who are high ED and hospital utilizers, and give them clinical oversight, maybe we could keep people healthier. Medicare saves money as a result, and studies have been done that show that creating these programs, it saves money. Of course, what I see that the patients receive is that they have a way to get through to medical support 24/7. They can call at 2 in the morning and get support, say, they’re running out of their blood pressure pills, or they have chest pain. I have had patients tell me this is the best thing that our clinic has ever done, it’s amazing. It is a really powerful service. And additionally, they call patients up and help them work on lifestyle modification. And some patients are simply lonely and this provides that benefit to them.

Have you encountered any challenges in implementing this program?

Brown: The biggest challenge has been educating my partners. It takes a while for them to realize the benefits of this; and it also involves educating our patients. A lot-of our patients are suspicious when someone calls them on the phone and they say, ‘I’m with White Wilson,’ and the patient says, ‘No, you’re not!’ So we have to train our professionals in how to interact with patients and explain to them what the program is about.

How have the physicians and patients responded?

Brown: We’ve had this program in place for six years now. Over that time, there’s been a tremendous warming to this program and acceptance of it. It’s been a year or two since I’ve had to have a face-to-face sit-down meeting with a colleague.

Wiacek: There has been a learning curve for everybody involved. And this augments the staff. This is a good thing, something that you want to take advantage of. And the same thing for the patients. We have the conversation with patients, and explain it to them.

“Mrs. Smith,” as we’ll call her—the typical patient living with multiple chronic diseases—is often at least somewhat confused and has historically lacked that regular connection with clinicians and health coaches, correct? And you’re helping Mrs. Smith to stay on track along multiple dimensions with this program, correct?

Brown: If Mrs. Smith is a smoker or overweight or is noncompliant, I can put in a little request to CareTrack in my documentation, asking them to remind Mrs. Smith to take a walk every day or cut down on alcohol intake. Or I can use the CareTrack people to contact Mrs. Smith about her lab results, etc. And I give her a card with CareTrack’s information on it, and I say, if you need something, don’t forget to use them.

Does this support your care delivery and management?

Oh yes. I’ve had people come in and say, this is the best thing that White Wilson has ever done. And this is a huge benefit for us. We see that and… and people who have memory issues keeping track of their medications and they forget they need a refill… or a patient comes in to see me and can’t keep track of their medications, they help us with that.

Wiacek: You could staff this up yourself and do it internally, but it would be a huge challenge to maintain. We can’t staff for the patients we see in-office, let alone for 24/7 nurse triage. It’s just very, very difficult to do this in this day and age. Here’s what’s different and why we chose CareTrack: this isn’t just a vendor and they’ve got nurse triage giving random advice. These people are part of Dr. Brown’s care team; they’re integrated.

I would imagine that this program is also helpful with regard to the clinician staffing issues that the healthcare system is experiencing now, particularly with regard to nurse staffing issues, correct?

Brown: This takes work off my office nurse, so she can help manage the patients coming into the office.

Wiacek: It did take a while before everyone saw the benefits. At first, it seemed like this was another thing we were asking people to do. So you’ve got to have a partner who will work for you, so it’s valuable for the patients and the practice.

Brown: When we look at how CareTrack operates, they provide a huge degree of flexibility in how they work with patients. Some patients are willing to participate, but at a distant level. Some patients want to initiate the contact, and CareTrack is fine with that. Some patients want to be contacted monthly. And the most intensive element is remote patient monitoring, involving blood pressure cuffs, diabetes monitoring, etc. And CareTrack does an incredible job of caring for those patients and keeping the doctor looped in. Some patients have crazy blood pressure issues; for diabetes, for COPD, these tools are indescribably important.

What kind of advice would you offer to your colleagues in other multispecialty medical groups?

Brown: Do this—just for your patients’ sake. That’s why we go into medicine, to care for people; that’s a sacred responsibility. And with that in mind, this is a huge step forward to fulfilling that role and caring for your patients.

Wiacek: That’s obviously number one. But it’s also financially responsible to do this kind of work, as we can help to lower the overall cost of care for patients, while we’re being reimbursed sufficiently. Everybody wins.

Brown: That’s right: you’re averting ED visits and the reimbursement that has to go to paying for very high-cost ED care. And it’s important to note that our Eds are overwhelmed anyway, these days.

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