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Comprehensive Care Management Tariffs Frequently Asked Questions: Clinics Working with and in Multi-Disciplinary Teams

Purpose:

We have been asked by clinicians to clarify some of the requirements within the CCM tariff as it relates to clinics with a multi-disciplinary teams. Specifically, clinicians had questions regarding 2 areas:

  • Ongoing communication with the patient, monitoring of patient condition(s) and the patient’s care plan, and
  • Ongoing coordination with other health care providers respecting management of patient condition(s) and the patient’s care plan.

Q. What do we mean when we refer to a physician or member of his/her (primary care) team?

A:  A primary care team is a group of professionals from different disciplines who communicate and work together in a formal arrangement to collectively care for a patient population in a primary care setting – whether in the same building or virtually. Examples of common primary care settings are family physicians’ offices or practices and community health centres. These teams often comprise but are not limited to: family physicians or general practitioners; nurse practitioners; other nurses; and other professionals, including dietitians, nutritionists, social workers, mental health counsellors, psychologists, pharmacists, exercise physiologists, physical therapists, and physician assistants. 

Q: What is required to claim the CCM tariff for patients seen by other members of the team at my clinic?

A:  A Physician may claim the CCM Tariff for their Enrolled patient for whom they are indicated as the Most Responsible Provider and for whom the physician or a member of his/her team provided medical services consistent with the applicable indicators in the Manitoba Primary Care Quality Indicators Guide and documented these services in the EMR.

The primary care quality indicator services may be performed and documented by the physician or members of the physician’s team.

Co-location of clinicians and interprofessional providers that provide only episodic coverage and services to a patient would not be considered team-based care.

Q:  If the physician (MRP) did not make a claim for a primary care visit with the enrolled patient this year, will the CCM claim be rejected?

A:  If the physician claiming the CCM tariff for a patient hasn’t had a successful claim for a primary care visit, the CCM claim will be initially rejected.

Physicians should query those rejected CCM claims and provide evidence of coordination and/or communication with members of the team having provided the patient ongoing comprehensive care during the preceding twelve (12) months.

Following are some examples of supporting documentation in the patient’s electronic medical record that could be used in a query for evidence of a physician who is engaging in teamwork, in order to demonstrate taking onus of a patient’s care:

  • Ongoing coordination with other health care providers respecting management of patient condition(s) and the patient’s care plan
    • This means that various clinicians are sharing clinical judgement and perspectives with one another to ensure the patient experiences optimal health outcomes. Examples of this clinical documentation could include, but are not limited to:
      • As per professional charting requirements, notations in the patient’s chart where clinical judgement was provided and/or direction noted by a member of the multidisciplinary team
      • Documentation of regular reviews of patient indicator reminders
      • Reviewing and providing feedback on a patient’s medical record
      • Documented communication (e.g. in person, electronic phone call, fax) with other providers or specialists to facilitate warm-hand-offs and/or informational continuity, such as care plans with noted care management responsibilities
      • Documented case-conferences to discuss and plan care
  • Ongoing communication with the patient, monitoring of patient condition(s) and the patient’s care plan.
    • This means various clinicians are corresponding with the patient (in and out of clinic visit) and/or, reviewing the patient care plan and means clinical judgement is being applied. Examples of this clinical documentation could include, but are not limited to:
      • As per professional charting requirements, notations in the patient’s chart where clinical judgement was provided and/or direction noted by a member of the multidisciplinary team
      • Scheduled in the medical record or EMR for follow-up consultation with another member of the multidisciplinary team
      • Care plan listing each provider’s role and responsibilities – could also indicate timing and responsibility of ordering/reviewing of tests
      • Documenting the handling post-visit questions and issues (e.g., quick conjoint or follow-up meeting, phone call to patient)
      • Documentation of the sharing of information, self-management support, community resources and organizations with patient (including to address social and environmental issues).

Depending upon the functionality in the EMR, this information may or may not be available in a way that is easily reportable for many patients at once. This information could be captured in the notes of the patient’s medical record, where the provider may have documented coordination of care or communication to the patient or other provider. In addition, some of these actions or providers roles could be captured in a patient care plan.

Primary Health Care Branch
1090-300 Carlton Street
Tel:  204-788-6732
Fax: 204-943-5305
Email:  phc@gov.mb.ca