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Advance Care Planning

How to Streamline Advance Care Planning at Your Provider Organization

March 5th, 2024 | 5 min. read



Content Team

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Since 2016, Medicare has reimbursed physicians for Advance Care Planning (ACP) counseling. Yet, despite studies indicating that most patients would rather die at home than in a hospital or nursing home, more than 25% do not die in their location of choice. 

While physicians may see the value of offering ACP, slow adoption stems from five reasons:

  • Confusion over billing practices and requirements
  • Lack of ACP processes that integrate seamlessly with clinical workflow
  • Uncomfortable discussing ACP with patients
  • Uncertainty about how to add another program to an already busy practice
  • Insufficient knowledge of how much revenue ACP could generate

ThoroughCare, supported by our integration with Honor My Decisions, provides a platform that addresses each of these five areas.

Our specialized tools enable physicians and their care teams to provide end-to-end advance care planning that’s billable, compliant, and easy to manage.

ThoroughCare offers an integrated ACP workflow

ThoroughCare forms the foundation of any advance care planning offering. We use an evidence-based workflow that guides the clinician and patient through a structured, yet flexible, set of steps.

The ACP workflow helps clinicians and staff ensure they’ve met time and legal documentation requirements, while also helping patients make decisions through video-based education that shepherds the conversation. 

While ThoroughCare provides the rigor, structure, and data capture and tracking capabilities, our integration with Honor My Decisions supports patient-centric conversations that facilitate medical decision-making. 

Screenshot 2024-02-29 113609

Figure 1 outlines each step in the ACP workflow found in ThoroughCare’s Annual Wellness Visit solution. This webinar video provides a more detailed walk-through of how ThoroughCare makes Advance Care Planning seamless and reliable.

Annual Wellness Visits support ACP conversations

Medicare reimburses providers for ACP discussions as an optional add-on to an Annual Wellness Visit. However, ACP consultation is free for patients when delivered with a wellness visit.

Inviting patients to engage in Advance Care Planning at other times is also appropriate. 

These could include when patients are discharged from the hospital, during Transitional Care Management (TCM) activities, when their health risk increases, or during a Chronic Care Management (CCM) check-in call. 

Note that, outside of the AWV, discussing ACP could be a billable service where patients may have additional payment responsibilities or copays.

ThoroughCare provides ACP documents for all 50 states

ThoroughCare asks all the necessary questions to create an advance directive that is compliant with the rules for all 50 US states. 

For those states that require an advance directive as one document, ThoroughCare creates a single document that includes the election of a healthcare proxy (aka healthcare power of attorney) and the patient’s healthcare preferences (aka Living Will). 

For those states that require two documents, ThoroughCare provides the required healthcare POA and Living Will separately.

Meeting time and billing requirements easily

With integrated time capture, ThoroughCare makes it easy to monitor and meet the minimum 16-minute time requirement for billing the ACP service as part of the Annual Wellness Visit.

The ACP workflow also prompts a final review of the time spent, the supervising provider, and coverage of specific ACP topics to ensure that Medicare requirements are met.

Creating documentation for future billing is straightforward, and the patient dashboard highlights each step in the ACP workflow, ensuring that every required area is adequately addressed.

Honor patient wishes and share ACP documents

Once the advance directive is created, it’s critical that ACP documents are shared and updated periodically. The goal of ACP is to adhere to the patient's healthcare preferences, which can only be achieved if everyone who needs a copy of the advance directive can access it, including:

  • Specialist physicians
  • Preferred hospital
  • Healthcare proxy and backup
  • Other family members and caregivers

ThoroughCare offers several ways to share the advance directive via:

  • Printed copies
  • Emailed copies
  • 24/7 access to the latest version of ACP documents via:
               - Patient’s personalized URL 
               - QR code 
               - Patient wallet card
               - Link in the provider’s EHR

Build skills and confidence to facilitate ACP 

With Honor My Decisions’ facilitator portal, ThoroughCare supplies a suite of tools and online training that enables clinicians to confidently broach advance care topics and lead person-centric, high-quality ACP conversations.

Start providing and billing for Advance Care Planning

Adding Advance Care Planning to an Annual Wellness Visit makes the process easier to implement. ThoroughCare walks the clinician and patient through every step with clear guidance and educational support. 

Using the platform eliminates barriers to launching a systematic and organized approach to providing ACP services. 

ThoroughCare equips providers and families to make informed, patient-compliant medical decisions

ACP has become a provider priority, supported by reimbursement and research. By using ThoroughCare, care delivery organizations can confidently provide ACP counseling as a covered service.

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