Frequently Asked Questions

Your practice will be required to remit a percentage of the practice’s collections for CCM services and AWV services. The exact percentage is determined through the use of a Fair Market Value (FMV) assessment. Specifically, it was calculated using the ratio of Work RVU’s to Total RVU’s. This methodology was reviewed by the CIN’s Quality Improvement and Population Health Committee and approved by the CIN’s Management Board.
The practice is only required to remit collection for the CCM or AWM Services performed by CIN Health Coaches on behalf of the practice. The practice is not required to remit a percentage of collections for those CCM and AWM services rendered by the practice’s employed staff.
Historical claims data and current clinical information for all ACO assigned beneficiaries will be reviewed and stratified using the ACO’s risk stratification tools and applications. Patients will be ranked according to several different criteria and assigned to a RN Health Coach. Health Coaches will build a panel of patients from the practices that they serve.
Yes. The contract for CCM services applies only to those patients that have not already been assigned to an existing Medicaid Health Home. For example, Medicare beneficiaries with both Medicare and Medicaid coverage (dual eligible enrollees) may be assigned to a Medicaid Health Home that is not affiliated with the Trinity Health Integrated Care ACO. Incidentally, your practice may refer patients to any eligible participating Medicare provider regardless of their participation with the Trinity Health Integrated Care ACO.
Our CIN/ACO Health Coaching efforts focus on high cost, high risk, attributed patients, a small percentage of your overall patient population. Each Health Coach, RN receives a list of risk stratified patients to reach out to and to add to their care team. Therefore, not all CIN/ACO patients will fall under the care of a Health Coach. The expected care team of each Health Coach, RN is approximately 80-100 patients.  
  • The Health Coach engages with high risk, attributed patients telephonically for care management.
  • The Health Coach initiates the collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes.
  • The Health Coach helps patients gain the knowledge, skills, tools and confidence to become active participants in their care so that they can reach their self-identified health goals.
  • The Health Coach ensures that the patients are aware of Red Flag Symptoms specific to their disease process, reviews medications and ensures that the patients are knowledgeable about the medications that they take, and supports the patient in identifying and reaching their personal goals.
  • The Health Coach will notify you or your office with any identified change in condition or if they identify that the patient is not following your prescribed plan.
  • The Health Coach will also notify you of a positive Depression, Anxiety, or Fall Screen.
  • If the Health Coach identifies a resource need that requires a Physician order (such as home health care) you will receive a flag/alert containing the details.
The Health Coach does not interfere with your patient care, practice clinical medicine, direct patient care, or provide treatments or medications.
Patients are attributed to the ACQA based on their claims for services through their Primary Care Provider and having Excellus coverage; Patients are attributed to our ACO by CMS based on their claims for services, sometimes through their PCP and sometimes via a specialist, and all have Fee for Service Medicare, also called Traditional Medicare. We are not currently working with patients who have Medicare Advantage or other forms of managed Medicare.
The frequency of the contacts depends on the needs of the patients. Some may need multiple contacts in one week while others may not need a contact for a few weeks. The minimum expected interaction is at least once, every other week.
The length of time that a patient stays on a Health Coach’s care team depends on the needs of the patient. Care management services would remain in place when there is an identified physical/behavioral/social concern that would benefit from care management interventions. Typically, a patient remains in active care management until they have met and sustained behavioral and/or physical goals and/or they have met personal goals as outlined in the care plan/self-management plan. An expected timeframe is 3-4 months but some patients may remain in care management for a longer or shorter duration of time.
We know that not all patients need the same intervention. A unique feature of the Health Coach care management program is the strategic identification of patients who will benefit. Rather than a traditional referral program, we will be Case Finding based on Reports and Registries, which combine clinical and claims based data and utilize predictive analytics. Each Health Coach regularly receives updated, current lists of patients that have been risk stratified and identified as high risk, attributed patients to reach out to and manage.  The Health Coaches are responsible for monitoring and interacting with these patients only.  In order to meet expectations of care team volumes and be successful in our collaborative care management efforts, our focus must remain on these patients.
Yes, there is an expectation that all groups will invest in and support the infrastructure for care coordination and follow a path towards eventual EMR implementation. Effective January 2025, all EMR's will be required, and have the ability to submit a QRDA1 file.