The Medicare Suite of Services is a term I’ve coined to describe a cluster of services to older adult patients that FQHCs provide that meet the needs of an aging population in a way that addresses priorities identified by the Centers for Medicare and Medicaid (CMS). These high priority services are meant to help older adults to more proactively manage health risks, stay healthier longer, and reduce the amount of costly emergency care. These include:

• Welcome to Medicare Visit
• Annual Wellness Visit
• Preventive Services
• Chronic Care Management

When patients are provided integrative and highly responsive care, FQHCs will find that many patients utilize all of the types of services listed above. These services can be considered interrelated clinically, clustered and internally managed by a cross-functional team as a Medicare Suite of Services. However, they are not billed as bundled, but billed as separate services. They require workflow and clinical protocols, checklists, and an engaged QI process. An active program enables the FQHC to use the Welcome to Medicare Visit, and the AWV as tools to work jointly with the patient to identify areas for screening, prevention and chronic care management. A patient with multiple chronic diseases will have regular monthly contact with the FQHC.

The preventive services include screenings for many risk factors and chronic conditions; alcohol screening and behavioral counseling; screening for depression; medical nutrition therapy; diabetes self-management training; glaucoma screening; lung cancer screening; smoking and tobacco cessation; and intensive behavioral therapy for cardiovascular disease and obesity.

Chronic care management services are offered to patients who have 2 or more co-existing chronic conditions that are expected to last more than a year. Some of the chronic conditions include arthritis, asthma, diabetes, hypertension, heart disease, and osteoporosis. The CCM approved scope of services consisting of 8 core elements, includes: a patient-centered jointly developed care plan; at least 20 minutes a month of case management; personalized help from a health care professional to manage care; continuity of care; care coordination among different providers; 24/7 emergency access; multiple methods for communication including secure internet and web communications; and electronic health record (EHR).

There are additional services for older adults not funded by CMS,  that can provide invaluable resources to your Medicare patients, especially those who are poor or living on limited incomes. Your FQHC can provide some of these services, like Benefits CheckUp by working closely with the National Council on Aging (NCOA), and/or by helping elderly patients access them through the local Senior Center or benefits enrollment staff (PEMOSSAs), including:

• NCOA’s Benefits Check Up (to access benefits and resources) (www.benefitscheckup.org)
• Senior Center (congregate and home delivered meals, programs, transportation).

Since this article was written in 2018, a number of FQHCs have reported that the Medicare Suite of Services has many cumbersome clinical and administrative requirements that make it difficult to implement. It will be interesting to see how FQHCs have developed this work over recent years, how the work has been impacted by Covid, and how the growing number of older adults impacts the work of FQHCs.

This article was developed for a presentation to the New Mexico Public Health Association’s Annual Conference, April 2018.

Anne Hays Egan, New Ventures Consulting, All Rights Reserved 4/4/2018 Updated 9/15/2022