Leading the Transformation of Healthcare

Ambulatory Geriatric Care

Do you need help supporting care of your elderly patients with multiple complex medical problems who need extra time or are home bound? Inova Geriatrics and Advanced Illness has two ambulatory service lines to care for patients who are complex and at high risk:

  1. In the Geriatrics and Advanced Illness Clinic, a multidisciplinary team provides expertise in evaluation and management of complex geriatric and advanced illness. The clinic offers consultative or primary care to patients with memory concerns, functional challenges, depression/anxiety, medication management, driving ability concerns, falls, incontinence, advance care planning and concerns about managing in the home environment. You can choose to stay patients’ primary care provider and obtain consultative services from the geriatrician at this clinic, or if desired, transfer patient’s care to the geriatrician.
  2. In Medical House Calls program, comprehensive primary care is provided by a physician or mid-level provider in patient homes and assisted living facilities for homebound patients with advanced or complex illness.

Both the Advanced Illness Clinic and House Calls program offer longer appointment times, are covered by most insurances, and include 24/7 provider on-call. Referrals can be made by calling 703-698-2431 or via Fax (571-665-6878). For more information, contact Robin Shultz (Robin.Shultz@Inova.Org).

Transitional Care Management

Transitional Care Management (TCM) refers to the service provided to patients during transitions in care from a hospital or other health care facility to a community setting. Hospital setting may include Inpatient acute care hospital, Inpatient psychiatric care hospital, Long term care hospital, Skilled nursing facility, Inpatient rehab, Hospital outpatient observation or Partial hospitalization. Home setting may include Home, Domiciliary (residential facility with treatment programs for a variety of issues, such as disabled veterans), Rest home (residential institution) or Assisted living facility.

Why is this important?

When leaving the hospital:

  • Almost one in five elderly patients return to hospital for care within 30 days
  • One third can’t explain their medications (means they do not know to take medication correctly)
  • 50% patients can’t state their diagnoses
  • 75% of chronically ill patients won’t need to make a return trip to the hospital if they had a plan for follow-up care

Extra support provided during transition of care from hospital setting to home setting improves care, enhances quality of life for our patients, and reduces hospital readmission.

Required Components of Transitional Care Management:

  1. Interactive Contact with the patient or caregiver within 2 business days (Mon – Fri except holidays) following a discharge. This contact is intended to:
  • Obtain and review discharge information
  • Review need for and or follow up on pending test/treatments
  • Education of the patient, family member or caregiver
  • Establish or re-establish with community providers and services
  • Assist in scheduling follow up visits with providers and services

Contact may be made via telephone, email, or face-to-face. Attempts to communicate should continue after the first two attempts within the required two business days until a contact is successful. If two or more separate attempts are made in a timely manner, and documented in the medical record, but are unsuccessful and all other TCM criteria are met, TCM service can still be reported/billed.

  • Face-to-face visit within 7 or 14 days
  • Medication reconciliation must be performed at this visit if not already done so during earlier contact
  • Medical Decision Making of Moderate or High Complexity

Moderate Complexity – e.g.

  • Multiple number of diagnoses or management options
  • Complexity of data to be reviewed is considered moderate
  • Risk of significant complications, morbidity or mortality is considered moderate

High Complexity – e.g.

  • Extensive number of diagnoses or management options
  • Complexity of data to be reviewed is considered extensive
  • Risk of significant complications, morbidity or mortality is considered extensive

Billing for Transitional Care Management:

Use the following CPT codes to appropriately code for TCM services –

  • 99495 – Medical decision making of moderate complexity during the service period; office visit with the Provider within 14 days of discharge
  • 99496 – Medical decision making of high complexity during the service period AND office visit with the Provider within 7 days of discharge

Care Management Program Update

The Signature Partners Nurse Navigator program provides high risk patients with additional assistance managing their health and living with a chronic disease. The Nurse Navigators work closely with the primary care physician and the patient to apply interventions and education to support the patient. Our Nurse Navigators create care plans after a face to face or telephonic assessment. The care plans will help the patients keep their wellness screenings current, chronic disease under control, reduce barriers to care, and enjoy a better quality of life. Nurse Navigators are assigned to provider offices by demographic area and priority high risk attribution.

Nurse Navigators can provide additional education and support to patients to help them manage chronic diseases such as Diabetes, CHF, COPD, and CAD. They can also assist patients with complex medical needs by connecting them to community resources and helping them navigate their care. Motivational interviewing techniques and teaching are key components of the program that help ensure the patients understand their disease process and how to self-manage their health.

Here are some of the ways we can help with your patients:

  • Navigate health care
  • Provide educational information
  • Support with managing chronic disease to facilitate self-management
  • Refer to Inova resources and community programs to support patients needs
  • Assist with setting up appointments to facilitate care
  • Follow up on referrals
  • Assist with continuity of care
  • Assist patients with personal barriers to care and self-management

Innovation Nurse Concierge Program – Licensed practical nurses and Registered nurses outreach Innovation Health patients who are at risk for further utilization or deterioration of health status based on claims and diagnosis. A telephonic outreach is placed to the patient to screen for needs in managing their health, assistance with coordination, and referrals to the high risk program with Nurse Navigator support if needed. Patients with multiple ED visits in 6 months are screened for access concerns, educational on site of care deficit, or other needs to manage their health to reduce ED visits.

New and Updated Signature Dashboards

Signature Partners is utilizing various analytical platforms (Koan Health and CedarGate Technologies) to produce new and improved Quality measures as well as Cost and Utilization dashboards for our providers to support them in their efforts of improving quality and reducing cost. We plan to bring the new Cost & Utilization dashboards to our practices in the coming weeks. We will continue to distribute the quality measure gap reports on a quarterly basis. Please use these quality measure scores and gap reports for reviewing trends in your practice and close the gaps as needed. Here is an overview of network quality scores as of Q3 2017

To view this chart in full size, please download here.

COPD Home Education Program

The management of COPD is complex and requires collaboration among PCPs, Pulmonologists, nurses, respiratory therapists, and case managers guiding patients about appropriate therapy to prevent frequent exacerbations that can result in decreased quality of life, multiple hospital visits, and increased health care cost. In addition to the medication management, education to improve self-management skills has been shown to be the key in improving quality of life and preventing frequent hospitalizations.

Signature Partners has collaborated with Respiratory Therapist team at Fairfax hospital, working under supervision of Pulmonologist Dr. James Lamberti, Medical Director, Respiratory Care Services at Inova Fairfax Hospital, to bring disease management education to our Innovation Health and MSSP patients at their home. This program is provided as “free of cost” to patients who may be unable to visit us in the clinic or may otherwise benefit from a visit at home where they are in a more relaxed setting and may be more receptive to learning about their disease and how to manage it; family members can also facilitate learning.

Signature Partners Case Managers, supported by Tonya Kirchmyer, Director of Care Coordination, introduce the program to eligible patients and will prompt the providers for an order. Provider referrals for complicated COPD patients are welcomed.

Quality Initiatives currently supported by Quality Consultants

Signature Partners Quality Consultants (QCIC’s) have been working on supporting the practices with the HCC risk coding evaluation, Aetna health risk assessments, enhancing the quality measures, and providing practices with patient lists to close clinical gap reports.  There is a QCIC aligned to each of the Signature Partner practices to review the data and develop and implement QI plans.  The QCICs visit the SPN practices as often as the work is required, but at least quarterly. They will be going to the practices again in August/September timeframe, with the pharmacy utilization reduction and ED utilization reduction data and strategies to educate the SPN practices on reducing utilization.


Currently, all Inova providers billing under our Tax IDs (TINs) will meet MIPS reporting requirements through our Medicare Shared Savings Program (MSSP).  Our ACO quality measures are reported through a web interface and all ACOs receive full credit for Improvement Activities.  Epic will report Advancing Care Information on behalf of our providers at the TIN level (one for primary care and one for specialty).  MIPS reporting replaced the requirements of the PQRS, Meaningful Use, and the Value Modifier programs impacting Part B claims (this year’s performance reporting impacts 2019 claims).

With the help of analysis from Cedargate Technologies, Signature Partners plans to administer a new, exclusively primary care, MSSP in 2018 (Track One +).  This model will qualify as an advanced alternative payment model; we plan to renew our current MSSP agreement, which does not take down-side risk (Track One), for the providers who would not likely meet the thresholds required to participate in an advanced alternative payment model.

GRPO Reporting Update

Our track one MSSP is currently in its final year (1Jan2015-31Dec2017).  On 4 Jan 2017, we received a file of 4,200 of our 33,000 beneficiaries ranked by CMS for performance year 2016 quality reporting on our 17 clinical quality measures.  We have abstracted all of the charts and are in the process of finalizing the XML file submitted through our vendor to CMS.  The GPRO reporting window closes 17March2017.  We will receive our official results in 3 Qtr. 2017 for the 2016 performance year; however, after a preliminary review, we expect to see an approximate 17% increase in points overall.


In April, Signature Partners will distribute practice level gap reports on our 2017 targeted quality measures for Innovation Health. We will also send a list to each practice that will identify the Innovation patients who currently have gaps in care. In April, we will receive the data to close out 2016 from Innovation and MSSP. We will produce and distribute the 2016 year-end Executive Dashboards in May. The Signature Partners Quality Coordinators will be reaching out to the practices to discuss the reports.

Quality Initiatives

Our Quality and Clinical Integration Committee has identified the following key initiatives:

  • Medicare Shared Savings Program (MSSP) – education and improvement in 34 accountable care organization measures
  • Innovation Health (IH) – narrow network – education and improvement in clinical and efficiency measures

– Risk Adjustment for MSSP and IH

  • The Advanced Illness Model (C-TAC/VQHC) – to improve care for patients with advanced illness and their families – education to providers on program.

– Virginia’s Physician Orders for Scope of Treatment (POST) – CME     development

  • Diabetes: Together 2 Goal® – AMGA program – education and diabetic outreach challenge (all practices to outreach their diabetics to schedule an office visit by June 30th).

– Retinal Group of Washington/IRIS Diabetic Eye Exam pilot

  • COPD, Early Diagnosis and Appropriate Management

– American Association of Respiratory Care Spirometry Training

  • Heart of Virginia Healthcare – AHRQ’s EvidenceNOW/Million Hearts (George Mason University and VCHI/VQHC)
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